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Applications Will Be Process 'Vhen Submitted Properly Completed. Be Sure Tr 'fin The Application. <br /> %W APPLICATION �, .==CEIVED MAR 3 11989 <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES IF VEHICLE INVOLVED, GIVE <br /> ENGINEER'S ANDrOR FOOD ESTABLISHMENTS,MOUSING Make - — <br /> APPLICANT'S AND/OR PUBLIC POOLS,WATER SAMPLING <br /> CONTRACTOR AND/OR REAL ESTATE INSPECTIONS Loc. No. - -�---� <br /> BROKER AND/OR POULTRY RANCHES AND KENNELS Reg iSt. No. - <br /> icFNSE ANO�OR MISCELLANEOUS SERVICES <br /> 3TRATION Color — <br /> FIER _ <br /> -Application Date <br /> _ = - _ Business/Name To Appear On Permit - — <br /> mType Permit/Service Requested: - � � Yyl fJ <br /> r _ — <br /> `Applicant Name W 'W Address <br /> rel��� -- --- - <br /> J953�L---,) _ Business Telephone No. Emergency Telephone No. <br /> 4 <br /> C <br /> Property Location/Address <br /> aProperty Owner_4 t-3 Address -- - - - - - <br /> Operator's Name -- 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 EmployeesALL 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 /> :ENNEL/Runways /Animal Population No. _ No. of Confining Cages. <br /> Sewage Disposal Method _ --- -- I C 3 -- -- <br /> Solid Waste Disposal Method —__ — -- <br /> Water Supply Source _ _ Animal Waste Disposal Method <br /> 6. CONSULTATION FEE <br /> i. PLAN CHECKING FEE <br /> 8. 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 re ul tions of the San Joaquin Local Health District. <br /> A, . A APPLICANT'S SIGNATURE X Title <br /> Gcalu a Date � - 3'0A <br /> FOR DEPARTMENT USE ONLY <br /> Fee I5 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 Q July 1 &Received By July 31 <br /> I REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE - I --�y .� >+r✓/ ---._ .---- �'C� �. <br /> LESS I {� <br /> PRORATION f'-L��3, _ �'� II N pn <br /> PLUS DAYS C'i';�i I i�i�L�1�,�v !L. <br /> PENALTY <br /> OTHER F1.t=- 2•� �1�— �_oL' I� ._3/389----- _._-_ _ <br /> OTHER I W <br /> Received by — Date Receipl No Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE_P.O.Box 2009 STOCKTON,CA 95201 <br />