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Applications Will Be Pr. Sed When Submitted Properly Completed. Be S, ro Sign The Application. viow APPLICATION `"' j ENVIRONMENTAL HEALTH PERMIT/SERVICES ENG?NEER�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'FNSE AND/OR POULTRY RANCHES AND KENNELS 3TRATION MISCELLANEOUS SERVICES Regist. No. I. .BER Color Application Date_ -'3/2 / _ Business/Name To Ap ea On Permit ,nType Permit/Service Requested: __ �n __ raw_ CtY1Sv/�� / _ - - ---- i Applicant Name 2OS IL __ _ - _ Business Telephone N Emergency Telephone No. . - - aProperty Location/Ad r�ess /S�Q _ ___ L'>'1__� C_A `Property Owner uiclu- F.4_1 ____ ►3 ,i �- _ Address __.�yD� N�c CN _. 6ITC416� Operator's Namehn AnrtA-. 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 -.. _ Water Supply Source _- Animal Waste Disposal Method 6./9 CONSULTATION FEE 3'S'" (Al, G.S 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 A _ 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 a rdance with San Joaquin County ordinances, state laws, anclfrules and reg'uulllat ' ns of the San Joaquin Local Health District. APPLICANT'S SIGNATURE X /�/;� f� Title `D Y� Date 29 - 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 DATE DATE REMITTED AMOUNT DUE CHECKED _ AMOUNT FEE + �J - _ —---- 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.Bo:2009 STOCKTON,CA 95201