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Applications Will Be Pro,-ssed When Submitted Properly Completed. Be Sure.To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOR AND%OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lia. No. <br /> .Ir'ENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No.._ <br /> I. .BER _ J Collor <br /> 'Application Date .-��` Business/Name To Appear On Permit <br /> Type Permit/Service Requested: _ <br /> p <br /> UApplicant Name E��2.,�� 2 �_ _. //Add'dress Pt'l-CIC �1Z �. deLcP-d7 C� 953 <br /> a Busine s Telephone No i_L_b9�.�� :.Lv�l Emergency Telephone No.— 17-S3yS <br /> 'a Property Location/Addre smrid_.- Sr $'_,,.. SCS ____„ <br /> Property Owner �!z . r 4• �1_�`_._ —___ Address . �.�/n5_ f"l�lrn <br /> a --.. <br /> Operator's Name 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 ❑ 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 /> r :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 /> 6. CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE - - <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection Sample Title Company <br /> Sewage System Inspection ❑ 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�andulations of the San Joaquin Local Health District. <br /> ,It <br /> APPLICANT'S SIGNATURE X _. --.. --- Title..P"U_,$C�__j-_eV4Date S"lr" 88 <br /> 1" FOR DEPARTMENT USE ONLY <br /> 1 <br /> V1 Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 11 EACH_ ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> \" BASE EXPLANATION AMOUNT DUE CHECKED <br /> (� + DATE DATE REMITTED AMOUNT <br /> Sr <br /> FEE <br /> LESS til — <br /> PRORATION + _ <br /> PLUS <br /> PENALTY <br /> OTHER + <br /> OTHER <br /> RiPICANT— <br /> d by Date Receipt No Permit No. Issuance Date Mailed Delivered <br /> RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />