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Applications Will Be Pr ssed When Submitted Properly Completed. Be S To Sign The Application. �I <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR F000 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 Reg ISL No. <br /> I. .8ER Color <br /> [Application Date 8��/9s- Business/Name To Appear On Permit L E'/Kywo <br /> vat Type Permit/Service�Requested: ��« TiE.x a �rAe..rrec 4yL4`�ner✓ <br /> i Applicant Name _[]�F/N�CrY �l, Z", r—. Address 3077 Fi TF �rACC t4r�SAutKFAw mvJ'aA <br /> G_— 7 Business Tele hone No. GG'�701 9/f.)GL4-93/t <br /> p . Emergency Telephone No. <br /> -376 <br /> &Property Location/Address •Zye/ MAc f'Aus77VCx �ArV<; i AC)f LA. `5 <br /> MProperty Owner GE/A[/NB 40,VS Address Sw•»qr <br /> L Operator's Name SA^.r Address Sna.a <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 /> F !ENNEVRunways _— /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method— <br /> Water Supply Source Animal Waste Disposal Method PAYMENT <br /> 6. O CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE <br /> ✓ <br /> 6. REAL ESTATEGneuT X:v}j#evz-%x v AU <br /> G 19 159Z <br /> REQUEST: Water Well Inspection Sample❑ Title Company <br /> Sewage System Inspection ❑ Address <br /> Escrow No. cPdVIHUNMENTAI He LTH Ui'ViL--. ., <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, <br /> `and <br /> d rules and regulations oftheSan Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X v"� ~' /+�AnrA 80-r/1Title `^oiraT 6%t440G eb Date a/�/'. <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 a Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <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.Boa 2009 STOCKTON,CA 95201 <br />