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Applications Will be Process When Submitted Pruperly Completed. be Sure 11 yn 1he Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S ANB/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR F000 ESTABLISHMENTS,MOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. __- <br /> LICENSE AND/OR POULTRY RANCHES AND KENNELS <br /> REGISTRATION MISCELLANEOUS SERVICES Reglst. No. <br /> ht1MBER - -1 T A4a 1 PK Color - __-- <br /> f Application Date Business/Name To Appear On PermitLY�Q L'�.1 l�lj'J✓! �h' ► i _ _ <br /> anType Permit/Service Requested: . <br /> u Applicant Name CA-_640,40" �.�(-I�� _ -_ Address �e LS__�1-��� �� WA <br /> ��1l� �+r —� <br /> _ Business� Telephone <br /> ��No.G�iSD� �'��.7.1.�ZZ Emergency Telephone No. -•+0111 <br /> CL <br /> i Property Location/Address ,, A /� <br /> iProperty Owner ,.�_bf,V�y?S_�_ - Address _SY - -S r---C�Q� �-L�� �T� _-- <br /> LOperator's Name !0_i -_ -_ 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 3 <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 /> 0 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 /> E3 KENNEL/Runways /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method est_► .�-1s1G. ---- -- -- --- - -- ---- - -- <br /> Solid Waste Disposal Method �� —,1_ - ----- ---- -- <br /> Water Supply Source 614 l 1••,,k-rm �9SLAnimal Waste Disposal Method <br /> 6. ❑ CONSULTATION FEE ---------- — <br /> 7. 14 PLAN CHECKING FEE ---- - --- -- -- <br /> B. REAL ESTATE <br /> REQUEST Water Well Inspection El Sample El 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 f the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X - Title (500)CV14`-{ Ole. Date --- <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 16 Received By January 31 ❑ July I A Received By July 31 <br /> -- ----- - - - REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> iDATE DATE REMITTED AMOUNT <br /> FEE - — - - - - - — <br /> LESS 1 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1 <br /> 1r•r,ewed by Dale---- - Recew,No Permit Nu Issuance Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.0 Box 2009 STOCKTON.CA 95201 <br />