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E41RONMENTAL HEALTH PERMIT/SERVIC <br /> ENGINEn S AND OR IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND'OP FOOD ESTABLISHMENTS.HOUSING Make <br /> CONTRACTOR AND OP PUBLIC POOLS.WATER SAMPLING <br /> BROKER AND OR REAL ESTATE INSPECTIONS LIc. No. <br /> Ir SEE]AND OR POULTRY RANCHES AND KENNELS Reglst. No. <br /> r RATION MISCELLANEOUS SERVICES -- ---- — — <br /> Color <br /> Application Date /D— 17-13 Business/Name To Appear On Permit _uo Q_C Gl-1 _ �-'L-r y1�4 5faL ro _. <br /> m Type Permit/Service <br /> Requested ---- - --- ---- — .— — <br /> Applicant Name KFr�0.' ('c n <br /> . Eng1'/111!.Gr1Qg lit CAddress 1'. <br /> U J J 6-6.6 <br /> Vnn .i7 Bu{m s Telephorol No-_.. __.n __. .. --_. Emergency Telephone No. <br /> .Property Location/Address w _6_J'.a1.fI-- fib.-tom --- — --- -- - <br /> Property Owner ___._.____—__... _ Address -- -----------_--- <br /> Operator's <br /> ddress .— <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 /> ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHIC <br /> 11 VENDING MACHINES/No. of __—. <br /> [1 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 OCCU <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 /> #SECTOR CONTROL- ❑ POULTRY FARM/Maximum No.of Birds _ <br /> NNEL/Runways -_ /Animal Population No. - No.of Confining Cages <br /> Sewage Disposal Method - <br /> Solid Waste Disposal Method — <br /> Water Supply Source ._ Animal Waste Disposal Me od <br /> 6. Jia CONSULTATION FEE IFS-ECY I� — OIaS2 [S So( c'<rn ✓Q Off) <br /> 7. ❑ PLAN CHECKING FEE <br /> S. 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 - 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 A Received By July 31 <br /> S REMIT <br /> BILLING REMITTANCE <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED - AMOUNT <br /> FEE �' S-� •0 hr. 35.00 x - <br /> LESS — <br /> PRORATION n ... <br /> t�ENARE 1 _ f.7t :..•. T� i�. 3I <br /> PLUS DA}'S ff ",�. U�ACCO <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuame Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Boa 21109 STOCKTON,CA 95]01 <br />