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Applications Will Be Pro, ed When Submitted Properly Completed. Be Su.' -o Sign The Application. APPLICATION ..� + ENVIRONMENTAL HEALTH PERMIT/SERVICES 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. - irFNSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. 3TRATION MISCELLANEOUS SERVICES g i. .BER Color _ i Application Date 1 _ _ 1 B siness/Name To Appear On Permit f�S �/IUi�Orn��rt oType Permit/Service Requested: 13Z'� -_ __ T _ _ iApplicant Name 75- 'Emu, ---e.n. --- _-- Address �/fgicec��t^ Busine s Tel phone No. c 209 3YT`/-/o y/ Emergency Telephone No 'a Property Location/Addre Property Owner. ��L --_-_F4'�a�d - -. -._ Address SMC Operator's Name ` __ —__�I_.._ _- _ 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 ❑ NATURAJ 5. VECTOR CONTROL 11POULTRY FARM/Maximum No. of Birds --. -_-- .-- ---_-- t" / r :ENNEL/Runways /Animal Population No. No. of ConfiningPages`j Sewage Disposal Method _ — ____- / - Solid Waste Disposal Method Water upply Source __ _______ Animal Waste Disposal Methocyr�i J/'/ 6. CONSULTATION FEE -� /r f " 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 Title Date 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 - -- �� REMIT BILLING REMITTANCE $ BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS - - - - - ----- PENALTY OTHER OTHER Recewed 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