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Applications Will He ProcesWhen Submitted Properly Compieteo. be Sure 1 u ' iyn 1 he Application. / <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S ANO/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR (000 ESTABLISHMENTS.HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOL&WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> LICENSE AND/OR POULTRY RANCHES AND KENNELS <br /> RF6}9T"TION MISCELLANEOUS SERVICES Regist. NO. _ <br /> a __ 1�-_RGI. NT A49� RK Color - <br /> (Application Date S 8 Business/Name To A pear On Permit <br /> MType Permit/Service Requested: <br /> G/o SLGIlaAI►1�c.1� S-4 112s Address �� s� I9oi' o Z hoed, t4A► 98032 <br /> Applicant Name �> 4F. <br /> U w <br /> Business Telephone No. -4d0✓�- <br /> � <br /> - Z�'��lZ _ Emergency Telephone No. <br /> (Property Location/Address \✓IL-50A At *kv7I' �T) STO�mN G� — <br /> -_'j Property Owner �� �T'/�.1�0(C�Cee� _1_C"'bV��_i_-_ Address <br /> , t �� S� �LOwfc-� SZ• LAI) C+� <br /> Operator's Name �� ` �_— ip ---- 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 ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> a KENNEL/Runways __ /Animal Population No. ___ No. of Confining Cages _ <br /> Sewage Disposal Method e ITY or GKVA <br /> Solid Waste Disposal Method p /� <br /> Water Supply Sourcej-�_`�T�!`. W,_ Animal Waste Disposal Method <br /> 6. ❑ CONSULTATION FEE —__- <br /> 7. 1K PLAN CHECKING FEE <br /> B. 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. and rules and regulations of the San Joaquin Local H�alltthh DistrT. <br /> APPLICANT'S SIGNATURE X __- —_ TitieTvcoii,%n ATSk Date ____ <br /> 14 -FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I d Received By January 31 ❑ July 1 A Received By July 31 <br /> r--- - -T— REMIT <br /> BASE EXPLANATION BILLING REMITTANCE s AMOUNT OUE CHECKED <br /> DATE DATE REMITTED - AMOUNT <br /> FEE I <br /> LESS I{ <br /> PRORATION <br /> I'LUS <br /> PENALTY <br /> OTHER l <br /> OTHER <br /> Rer:ewe0 by Date Ree,.,..No Permit No lssuaixx Maded DehvereC <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E HAZELTON AVE..P.O.So. 2009 STOCKTON.CA 95201 <br />