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Applications Will Be Proo-tssed When Submitted Properly Completed. Be Sure To Sign The Application. • _ APPLICATION ENVIRONMENTAL HEALTH PERMIT/SERV�I°ES ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make — CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. . - ir'ENSE AND/OR POULTRY RANCHES AND KENNELS 3TRATION MISCELLANEOUS SERVICES Regist. No. I. .BER - Color L L/ Application Date IM _ t4_` �. .— Business/Name To Appear On Permit FType Permit/Service Requested: UApplicant Name ei f-- iv.r� Wcc. �./✓✓�'�` Address (71D is'J -- n Business Telephone No..—., 7 _CEmergency Telephone No. �'_.6��1 <Property Location/Address—_ o��c __ c. - - ZZ �L-4 f. m��/` ✓f.-S�-, — IProperty Owner C� _sof +Lt/c c __ _ Address -__. — j - ...___. Operator's Name L�= G1 - ---- Address 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE ❑ FOOD CROP HARVESTING/No. of Field Employees ALL APPLICANTS: Total Employees Including Operators 2. HOUSING ❑ HOTEL/MOTEL/No. of Units ____ __ ❑ CERTIFICATE OF OCCUPANCY ❑ MOBILE HOME PARK/No. of Spaces 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER NO. OF PUBLIC SERVED (Connections) _- 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds .ENNEL/Runways /Animal Population No. __. _ No. of Confining Cages Sewage Disposal Method Solid Waste Disposal Method Warter Source ___ _ Animal Waste Disposal Method 6.s CONSULTATION FEE 7. ❑ PLAN CHECKING FEE 8. REAL ESTATE REQUEST: Water Well Inspection Sample Title Company Sewage System Inspection ❑ Address Tele. No. Escrow No. — Seller _ Seller Address Telephone No. - _ _- Seller Agent Name Service Request For Date -- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and /^regulations of the San Joaquin Local Health District. APPLICANT'S SIGNATURE X �lL ! v_ Title _ _ «� —_ Date 12� � FOR DEPARTMENT USE ONLY Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE — LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201