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Applications WIII,�a Professed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> 'rNVIRONMENTAL HEALTH PERMIT/SERV LES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANTS 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 Regist. NO. <br /> 3TRATION MISCELLANEOUS SERVICES g <br /> i. .BER Color <br /> Application Date Bus iness/Na�'Ie To Appear O Per It <br /> FType Permit/Service Requested: "��,j� �d/Vt���z5171 Z+ . <br /> Applicant Name �Z'1YfLIA��1iJ��B � ,�U.nr. L._ __ Address �ll t _ <br /> s ° o Busl ess Telephone No. — — Emergency Telephone No. <br /> roperty Location/A re s j,�W G <br /> I Property w _ Address S 7 Q <br /> Operators Name CCh 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 <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 /> r :ENNEL/Runways /Animal Population No. - NO. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source _ Animal Naste Disposal Method <br /> 6. -N'-CONSULTATION 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 HENT <br /> Service Request For Date <br /> I hereby certify that I have prepared this application and that the work will be done in accordance withSanoaquin County <br /> ordinances, state laws, a ules and r��lati s of the n Joaquin Local Health District. � <br /> ' � % _l�� <br /> APPLICANT'S SIGNATURE X -. Title 10katVq4Z 16N <br /> F DEPARTMENT USE ONLY PERMIT�SER <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 $Received By July 31 <br /> BILLING REMITTANCE $ tAMOUNTDUE <br /> REMIT <br /> BASE EXPLANATION DATE DATE REMITTED CHECKED <br /> OO AMOUNT <br /> ACCOUN ISS, <br /> FEE 12 00 <br /> v. <br /> LESS <br /> PRORATION <br /> PENALTY P NA.L.TIES WIL BE APPLIED O PAST D <br /> 0M <br /> -BaR4G DATE <br /> OTHER <br /> OTHER <br /> Recet by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> A LICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />