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" , .Applications Will Be PrN Bed When Submitted Properly Completed. Be Sur-,ToSign The Application. <br /> APPLICATION y <br /> 64VIRONMENTAL HEALTH PERMIT/SERVIUES IF VEHICLE INVOLVED, GIVE <br /> ENGINEER'S AND/OR FOOD ESTABLISHMENTS.HOUSING Make -- <br /> APPLICANT'S AND/OR PUBLIC POOLS,WATER SAMPLING <br /> CONTRACTOR AND/OR REAL ESTATE INSPECTIONS Lic. No. — <br /> BROKER AND/OR POULTRY RANCHES AND KENNELS Regist. No.- <br /> IrcNSE AND/OR MISCELLANEOUS SERVICES <br /> STRATION Color <br /> I- .BER <br /> f Application Date Business/Name To Appear On Permit — — <br /> wType Permit/Service Requested — `� I�nl II 11'R n IYAU <br /> a Address <br /> Applicant Name —� r n- Fr•!- bl If-�yS. _ — -T ` <br /> Business Telephone No.---; Emergency Telephone No. <br /> J rty Local /A dress 1PQ 2`n Al ��H <br /> "Property Own (A S 1-/� -- 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 Cl BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE _ ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR_ <br /> ❑ VENDING MACHINES/No of <br /> -� ❑ MOBILE FOOD PREP. UNIT ID VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees -ALL APPLICANTS: Total Employees Including Operators pPAYhl <br /> 2. HOUSING ❑ CERTIFICATE OF'OGc.TFeyCY" T <br /> ❑ HOTEL/MOTEL/No. of Units <br /> ❑ MOBILE HOME PARK/No. of Spaces DEC 2 198 <br /> 3. WATER DUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER JEWRQ <br /> NO, OF PUBLIC SERVED (Connections) ppccnnNME� <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NAl'l4YSA )3/�. <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds - 3� kVICES <br /> r ".ENNEL/Runways /Animal Population No. _ No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method , <br /> Water Supply Source - .._ Animal Waste Disposal <br /> l,Method �,`(� 1 <br /> 6. CONSULTATION FEE 1161( T/ /Tl 1�'I/ I -r'wr-�'`n..�— -�s-kcb'. , (' <br /> 1 <br /> 7. 9:1PLAN 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 regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X Title Date FOR DEPARTMENT USE ONLY <br /> Fee Is Due::O ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 8 ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNTDUE CHECKED <br /> DATE DATE REMITTED AMOUNT_ <br /> I <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS „ <br /> PENALTY <br /> OTHER <br /> OTHER PENAI_T ES W c <br /> tONi BILLII - T COUNTe dJ <br /> eived by Date Receipt No Permle No Issuance Date Mailed Deliveretl <br /> APPLICANT—RETURMALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O Boa MN STOCKTON,LA 95301 <br />