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Applications Will be Proces nen Subrnilled Properly L:ornpieled. be Sufe 1, yn Ihr Application. <br /> APPLICATION <br /> y ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S ANO/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S ANC/OR F000 ESTAILISHMENTS.MOUSING Make <br /> CONTRACTOR AND/OR PU/LIC POOLS,WATER SAMPLING — <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. NO. <br /> LK.ENSE AND/OR POULTRY RANCHES AND KENNELS <br /> Rff115TRATION MISCELLANEOUS SERVICES RegiSt. NO. <br /> ptt"EK - - -- ---- Color -- - --- <br /> Ir Application Date �r Business/Name To Appear On Permit ._/�'G� <br /> .,Type Permit/Service Requested:��A R&V)� ���b � C'�✓1�/Q&K-}--- <br /> <Applicant Name_C,b�`_fP'*&.4ldt�0L La,+t�st--?Kc AddressCtia_s S.)-al 0 98037. <br /> Business Telephone No. 20�'B� �Z Emergency Telephone No. M IE <br /> Property Location/Address �1l,SOd.� WA� \�/11�NIh�f Q �1 <br /> Property Owner A <br /> �Ca TOOL-Bt7H _ �_ -- Address Circ S' Q� L it ,� L10► <br /> Operator's Name il1T! .(AM S9 LIM TCt>- - Address — <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT $ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees -- - <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> PUBLIC WATER SYSTEM a SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) _- - - <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds - <br /> 13 KENNEL/Runways - /Animal Population No. _._ No. of Confining Cages <br /> Sewage Disposal Method _-- <br /> Solid Waste Disposal Method CA G Oc�� �o <br /> Water Supply Source ` t_j5dot. Animal Waste Disposal Method <br /> 6. ❑ CONSULTATION FEE <br /> 7. % PLAN CHECKING FEE ---- <br /> e. REAL ESTATE <br /> REQUEST Water Well Inspection[] Sample[] Title Company <br /> Sewage System Inspection ❑ Address Tele- No. <br /> Escrow No <br /> Seller Seller Address <br /> Telephone No Seller Agent Name <br /> Service Request For Date <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws es and regulation of the San Joaquin Local Health District <br /> ftgm IT- <br /> APPLICANT'S SIGNATURE X ' Title I • nV)r'1Alboc. Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 b Received By January 31 ❑ July 1 b Received By July 31 <br /> -- -- I — REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE I REMITTED - AMOUNT <br /> FEE ---- — -- - I I _ _ — <br /> LES <br /> PRO <br /> PRORATION---� <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Ll--'ved Ay Oale Rece,pt No Permo No Issuance U.— Marled Delivered <br /> APPLICANT-RETURN ALL COPIES TO ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O eo■2009 STOCKTON.CA 95201 <br />