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Applications Will Be Pro sed When Submitted Properly Completed. Be SI 'o 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 Lic. NO. _--_- — <br /> IrENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES ReglSt. NO. <br /> I, .dER Color <br /> (Application Date_ $�J !a O _ B siness/Name To Appear On Peyrmit <br /> ,Type Permit/Service Requested: yLe [S _ <br /> a Applicant Namee2174- <br /> \ _ Addresses 3 ` S6 <br /> . � ` Bu i es s Telephone No. Emergency Telephone No. <br /> aProperty Location/Address <br /> `Property Owner_ _ - Address <br /> LOperator's Name _ Address <br /> 1. FOOD ESTABLISHME S 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 /> PAYMENT <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units <br /> ❑ CERTIFICATE OF OCCUPANCY RECEIVED <br /> ❑ MOBILE HOME PARK/No. of Spaces n <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL AUG 0 1 198 <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) ENVIRONMENTAL HEALTH <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLAdVRM I T/S ER VICES <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 SourceAnimal Wastjeispoossall Me)hod <br /> 6. W'CONSULTATION FEE » C1t-7 CL-lr /�44II w—r��s�='<ahQ� /V <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 rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ��- -- Title - �j1R QAP �� Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT_ <br /> FEE <br /> LESS .. ��� Al,PR6R*T1'ON <br /> PLUS <br /> PENALTY <br /> OTHER s2i'SD /�/(, S2.S8/ ue by 9117�88 <br /> OTHER «S D <br /> CA 0 <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.Box 2009 STOCKTON,CA 95201 <br />