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remlid VVI , Ip„ated. Be Sure To SICn The Ap1, . , ,. atlon . <br /> APPLICATION <br /> ENGINEER'S AND !QR tVIRONMENTAL HEALTH PERMIT/SER ' ES <br /> APPLICANT'S AND; Op FOOD ESTABLISHMENTS, HOUSING IF VEHICLE INVOLVED , GIVE <br /> CONTRACTOR AND /OR PUBLIC POOLS, WATER SAMPLING Make <br /> BROKER ANp/OR REAL ESTATE INSPECTIONS LiC . No . <br /> . <br /> tr'c, NSE ANo, OR POULTRY RANCHES ANO KENNELS <br /> 3TRA71ON MISCELLANEOUS SERVICES Regist , No . <br /> I , aGA _. <br /> Color <br /> ( AppllCatiOn Data . _ d 9 . . __ - <br /> . —_ Business/Name To Appear On Permit . . heA oc ( ,G�rrj ryl v <br /> Type Permit/ Service Re uested , , 2�61'i e [.O O-f - -- ----- -- <br /> Applicant Name S6LU cc <br /> AddressEA <br /> — - — Business Telephone No . . .. . . .. Emergency Telephone No . <br /> /CPN5-10 - ---..._ .. g Y P <br /> s Property Location�Address ._ ----••_ _ a// - JD . f_ Cra.n f Li , r . / 1 <br /> at Owner Or�1 ��� . -- Address 1 ,� 1HW wn <br /> L Operator ' s Name <br /> _ 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 ❑ ICI= PLANT ❑ BAKERY <br /> 0 ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE Q FOOD SALVAGER ❑ FOOD DEMONSTRATION C7 FOOD VENDOR 1 <br /> ❑ VENDING MACHINES/ No . of . . _ _--. . ... . ❑ MOBILE FOOp 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 /> ; 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 /> 61 Q CONSULTATION FEE �f�t Tf� I0' 2 ) jl vlry tn/ hli1C �iJ 'LxL, pci. <br /> i I t ra b!. <br /> 7 , ❑ PLAN CHECKING FEE _ <br /> b. REAL ESTATE <br /> REQUEST : Water Well Inspection ❑ Sample ❑ Tltle Company . _ . <br /> Sewage System Inspection 11 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 r le and regulations= o8quin Local Health District . <br /> APPLICANT ' S SIGNATURE <br /> X _ Z1u � .� ' � 6—. Title ° Date /9 . <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due : ❑ ANNUALLY ❑ PCR UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Rece ved Ely January 31 ❑ July 1 ,S Recelvad By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE j REMIT <br /> DAT [ DATE REMITTED AMOUNT DUE CHECKED <br /> _ — --• , . _�. <br /> FEE AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER I - " <br /> 01 HER I -�-� + —_ - _ <br /> Received by - - '—•— Date . —_ . R9C91p1 N6 Permit NO . . . . . ..— 16euAnGq Date Moiled . <br /> � ' Delivered <br /> APPLICANT — RETURN ALL COPIES TO : ENVIRONMENTAL HEALTH PeRMITi8EHVICEs 10i E. HAxELTON AVE. , P.O . Box 2009 STOCKTON, CA 95201 <br />