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Appllcns wltt 13ePracealseawne1l APPLICATION <br /> -IRONMENTAL HEALTH PERMIT/SERV s <br /> IF VEHICLE INVOLVED,GIVE <br /> ENG1NEEhS A170/GR {000 ESTABLISHMENTS.HOUSING Make <br /> APPLICANT'S ANDIOR PUBLIC POOLS.WATER SAMPLING <br /> CONTRACTOR AND/ORREAL ESTATE INSPECTIONS LIC. No. <br /> BROKER AND/OR <br /> i�-ENSE AND/OR POULTRY RANCHES ANO KENNELS Regist. No. <br /> ;TRATION MISCELLANEOUS SERVICES <br /> CiOIOr <br /> I. .aER <br /> (Application Dated Business/Name To Appear On Permit NteirS �A1�I/�ON/Y�N L O.�Gt��A.u�f . <br /> H Type Permit/Service Requested: �1 p,t��..��j <br /> .z Applicant Name t Lo-' <br /> ex s. �0•'dOX 103 Q'K.'eO Co.___, ysL/ <br /> a Business Telephone No. �y/u - Emergency Telephone No.Afl, ., <br /> ,Property Location/Ad ress y2 &Z .11 NF- Lo cli, CA• .. - <br /> `Property Owner �� Address DS <br /> :Operator's Name Address -y2O__-��7Ldr7JdA/_ - <br /> 1. FOOD ESTABLISHMENTS Total Buiilding 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/MOTEUNo. of Units ❑ CERTIFICATE OF OCCUPANCY 5 <br /> ❑ MOBILE HOME PARK/No.of Spaces i <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL 0 SO,/, 441 ,I <br /> ❑ PUBLIC WATER SYSTEM 13 SURFACE WATER SUPPLY ❑ WATER HAULER I <br /> NO. OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL 13'POULTRY FARM/Maximum No.of Birds <br /> :ENNEURunways /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method _ <br /> Solid Waste Disposal Method <br /> Water Supply Source __ Animal Wa to Disposal Method <br /> 6. 0 CONSULTATION FEE �/,�s z�rf 2a �.��S �es��,�e -:Z <br /> T. ❑ PLAN CHECKING FEE <br /> S. REAL ESTATE <br /> REQUEST: Water Well inspection❑ Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <br /> Escrow No. q, <br /> Seller Seller Address <br /> Telephone No. Seller Agent Name <br /> Service Request For Date <br /> I hereby certify that 1 have prepared this application and that the work will be done In accordance with San Joaquin County <br /> ordinances,state laws,and r es a reg i s of the San Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE XTitle <br /> to 8 <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 /> *+ REMIT <br /> BASE EXPLANATION BILLWIPA lvl t�^E S AMOUNTOUE CHECKED <br /> DAT REMITTED AMOUNT <br /> FEE <br /> FIS <br /> t 1 <br /> LES <br /> PLUS i r. <br /> PENALTY ENVIRONNENTAI <br /> OTHER PEW /SERVICES <br /> OTHER <br /> onr <br /> �9 <br /> r <br /> Received by Date Receipt No. Permit No laauence Date Mailed Delivered ' <br /> APPLICANT—RETUAN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1.6011.HAZELTON AVE„P.O.eon 20011 STOCKTON,CA 9SN <br /> T <br /> t <br />