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Apptipations Will Be Pr sed When Submitted Properly Completed Be S 9 <br /> o Sign The Application <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER S AMD/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 /> gIMNSE AND/OR POULTRY RANCHES AND KENNELS Re 1st No <br /> Wa�TRATION MISCELLANEOUS SERVICES <br /> g <br /> ER Color <br /> rApplication Date h /�g Business/Name To Appear On Permit to <br /> II ..Ll i <br /> &*Type Permit/Service Requested 1Rev+eu. of 6rroun�� Gl/ e !/�xrp r x prr�Dr7_Sc� <br /> 4Appllcant Name del rt�'�[rleh Ad ress 1 T5 Bless &±:k r+ue� .SUI C <br /> IL <br /> _5'r�Llra>�-tit'I CA_ X52 7 Business Telephone No �6 .3�� Emergent Telephone No <br /> LProperty Location/Address r QS _r..J n l'dLT <br /> "Property Owner 6� cy4pA L Yf Address �1�1._._._ .�fL`�Pr� FYacu Cid ?5 76 <br /> LOperator 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 pAYj'!L'NT <br /> ❑ HOTEL/MOTEL/No of Units ❑ CERTIFICATE OF OCCUPANCYRECEIyED <br /> ❑ MOBILE HOME PARK/No of Spaces JUN 2 <br /> 3 WATER QUALITY 11WATER SAMPLE {Bacterial) ❑ CHEMICAL V 4 1988 <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER FNV'Rp <br /> NO OF PUBLIC SERVED (Connections) N��MENtq[ M�A�Ta <br /> 4 RECREATIONAL HEALTH ❑ SWIMMING POOL C] SPA 13 WADING POOL 1:1 NATURAL BATH INGPAWI-SERVICES <br /> VECTOR CONTROL ❑ POULTRY FARM/Maximum No of Birds <br /> 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 CONSULTATION FEEw LOARer v-ri g 1e >h e <br /> 7 ❑ PLAN CHECKING FEE PinnnSc 111 �9$ �rizt.il��„� Q�12r�, TtaG�/�- Cislr raise �� <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 /> APPLICANTS SIGNATURE X Title r i 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 S FIE <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKREMIT <br /> ED <br /> AMOUNT_ i <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> ` PENALTY <br /> OTHER <br /> OTHER <br /> LA <br /> Received by Date Receipt No Permit No Issuance Date Mailed Delivered <br /> APPLICANT---RETURN ALL COPIES TO ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E HAZELTON AVE P O Box 2409 STOCKTON CA 9540 <br /> 1 <br />