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Applications Will Be Pr, ,sed When Submitted Properly Completed. Be Su To Sign The Application. <br /> r APPLICATION <br /> t ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> EWGANEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make — <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> IrENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> aER --- 2 Q, Color <br /> f Application Date ��?'_v__ Business/Name To Appear On Permit <br /> oType Permit/Service Requested: <br /> A licant Name pe •�� LAddress(,_19L Tj �I <br /> Lf <br /> a <br /> JA <br /> Business Tele p one No. _ Emergency Telephone No. <br /> 'a Property Location/Add ss <br /> -'j Property Owner Address — — <br /> L 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 Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING PAYMENT <br /> ❑ HOTEL/MOTEL/No. of Units — ❑ CERTIFICATE OF OCCUPANCR E C E I V E D <br /> ❑ MOBILE HOME PARK/No. of Spaces r, <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL FEB 10 198'i <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) ENVIRONMENTAL HEALTH <br /> 4. RECREATIONAL HEALTH 11 SWIMMING POOL ❑ SPA 11 WADING POOL ❑ NATURAL BATHING PCT Ai T/SERVICES <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <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 Method <br /> 6. gCONSULTATION FEE <br /> 7. 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 don in acco dance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local H alth <br /> APPLICANT'S SIGNATURE X - — Title Date <br /> FOR DEPARTMENT USE ONLY , <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEELESS <br /> l O <br /> PRORATION PEN <br /> PLUS DAYS FROM BILLING DATE, <br /> PENALTY <br /> OTHER O-D <br /> 7-2—:5 <br /> ) 1 12/27/88 <br /> •`J <br /> 25 <br /> Received by Date Receipt No Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />