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e 1 Applications Will Be Pr 0 <br /> sed When Submitted Properly Completed. Be S To Sign The Application. <br /> r 10 APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'SANO/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. N0. <br /> j IrENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES RegISI. NO.— <br /> I. .BER __—__—_.___..._.t._.. r Color <br /> (Application Date_—IO— 1 7 SS Business/Name To.Appear On Permit �CCk_5e'rj <br /> MII Type Permit/ServilGe/RR uesI d: C .�� (? <br /> `Applicant Name L�IP2 ixt 0.n Lnpl/12.earc r ACaddress go, Rn-,.( 3 e ic10.� � � /p <br /> _ <br /> Bu�in�5s Telepho No.�� — . Emergency Telephone No. <br /> `Property Location/Address_ �b11b r0.Gl^FT <br /> ,Property Owner -- Address _—_—__- <br /> -LOperator'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. <br /> perators __2. HOUSING PAYMENT' <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY RECEIVED <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER OCT 2 4 1988 <br /> NO. OF PUBLIC SERVED (Connections) F^f �� <br /> 4. RECREATIONAL HEALTH 11 SWIMMING POOL 11 SPA 11 WADING POOL 11 NATURAL BATHING'PY QNNMES RVI HEALTH <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 I#aste Disposal Me od <br /> 6. ><CONSULTATION FEE Ke.iirleW 1A r I" — 02 OhaSe, n� Soj <br /> 9. ❑ .PLAN CHECKING FEE <br /> 6. REAL ESTATE iA Y,\\On S ILO <br /> .,.FEQUEST: 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 Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 6 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE E <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT_ <br /> FEE �'S9S2 •0 hr. 35.00 X <br /> LESS <br /> PRORATION PENALTIE <br /> PPLUS <br /> ENALTY DAYS FR - TO `SI D UE ACCO <br /> OTHER <br /> OTHER o ��- - <br /> 2 <br /> eive0 Dy 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.Bort 2009 STOCKTON,CA 95201 <br />