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e n 5ubinittedPropeny--pi�,a... <br /> Q pl t S II e r APPLICATION GENERAL <br /> ENV1 ENTAL HEALTH PERMIT/SERVICES IF VEHICLE INVOLVED, GIVE I <br /> R ENGINEER'S AND/OR 7Cj0 FOOD ESTABLISHMENTS,HOUSING <br /> APPLICANT'S AND/OR PUBLIC POOLS,WATER SAMPLING Lic.LIC. NO. <br /> CONTRACTOR AND/OR n RfAI ESTATE INSPECTIONS <br /> BROKER ANDlOR SAN in %I��N LOCAL POULTRY RANCHES AND KENNELS Color--------- <br /> REGISTRATION <br /> No <br /> LICENSE AND/OR AN ,11 `1 MISCELLANEOUS SERVICES <br /> REGISTRATION HEALTH DIS STRICT y <br /> NUMBER <br /> 'J.- 64-A-S S Ge�I i2� <br /> ,5-7a-�.. Business/Name To Appear On Permit <br /> Application Date <br /> FType PermitlService�e�ue5te Ons Address p.0. BOX 1450 StOCk[oXl <br /> a r1si Emergency Telephone No. <br /> s <br /> Applicant Name 1 Business Telephone No. <br /> e a La din <br /> H� 12 & Glasscock Rd• <br /> .,Property Location/Address _`: Address <br /> aProperty Owner # Address <br /> L Operator's Name Footage Restaurant, Maximum Seating Capacity <br /> (Total Building Sq. g ❑ MEAT MARKET <br /> 1. FOOD ESTABLISHMENTS ❑ FOOD MARKET WHOLESALE C3 BAKERY c <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ti ❑ ICE PLANT" l <br /> ❑ FOOD PROCESSING P ❑ FOOD VENDOR <br /> LANT- -0-COMMISSARY ❑ BAR 11 ITINERANT RESTAURANT <br /> I ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE fi <br /> ' ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER 13-FOOD DEMONSTRATION C3 VENDING VEHICLE <br /> ❑ MOBILE FOOD PREP. UNIT <br /> ❑ VENDING MACHINES/No. of ' <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees <br /> ALL APPLICANTS: Total Employees Inciuding Operators <br /> ` 2. HOUSING E ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ HOTEL/MOTEL/No.of Units <br /> ❑ MOBILE HOME PARK/No. <br /> of Spaces <br /> SAMPLE ( ca tB erial) ❑ CHEMICAL <br /> 3. WATER QUALITY ❑ WATER HAULER <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY <br /> NO. OF PUBLIC SERVED (Connections) ❑ WADING POOL El NATURAL BATHING PLACE4, RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds N <br /> /Animal Population No. , of Confining Cages <br /> ❑ KENNEL/Runways _ — <br /> f Sewage Disposal Method <br /> Solid Waste Disposal Method Animal Waste Disposal Method <br /> Water Supply Source Reinspection 12 ''19179 C] BUSINESS LICENSE <br /> g. ❑ CONSULTATION FEE ❑ DANCE PERMIT <br /> U PLAN CHECKING FEE <br /> r g, REAL ESTATE Title Company Tele. No. <br /> REQUEST: Water We11 Inspection❑ Sap1e❑❑ Address <br /> Sewage System Inspection <br /> Escrow No. <br /> Seller Address <br /> .Seller <br /> Telephone No. Seller Agent Name <br /> f Service Request For Date <br /> have prepare re I application ulaof te Santhat the work Joaquin Local will <br /> District. <br /> ccordance with San Joaquin County <br /> 1 hereby certify that I <br /> ordinances, state laws, and rules a 9 <br /> Title Date <br /> t APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT-USE ONLY <br /> REMIT <br /> Fee IS Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 AMO❑T pUE &ReceiGHECKEOed Sy y 3i <br /> BILLING REMITTANCE REMITTED AMOUNT <br /> BASE EXPLANATION DATE DATE <br /> 1 $30.00 <br /> 7 g0 <br /> FEE $30.00 Reinspec ti n Fee` -- <br /> LESS <br /> PRORATION <br /> PLUS V <br /> PENALTY <br /> OTHER { Q <br /> OTTH�eE�R., <br /> -/!1 1 J� `O V f G Y�� Issuance Date Mailed 6e4ivered � <br /> ! ! Receipt No. Permit No. STOCKTON,CA SS20' <br /> Received by D to 1601 E..riAZELTON AVE.,P.D.BOY 20I?9'+,., <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />