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Applications Will Be Pro %ed When Submitted Properly Completed. Be Su To Sign The Application. <br /> 600 APPLICATION %./ <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S ANOiOR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND!OR FOOD ESTABLISHMENTS.HOUSING Make <br /> CONTRACTOR ANDIOR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND,OR REAL ESTATE INSPECTIONS Lic. No. <br /> Ir'ENSE ANDiOR POULTRY RANCHES AND KENNELS Regist. Na. <br /> ;TRATION MISCELLANEOUS SERVICES g - ---I. 6ER X57-554x79 Color,yf- /! <br /> S_.. . <br /> -Application Date A L4_ w6ii /<f,,l�l�z Bu mess/Name To Appear On Permit AQ � En-vL rll�e r/tr// I�r15l j--r <br /> oType Permit/Service Re ested: 5!p1) 0.111.rl _ <br /> UApplicant Name1 � -T �iri h nsfo n Address $_61 !-a, E r, <br /> ell', E . �,dl 17,1"5'.67a Business Telephon No. Emergent Telephone No. <br /> -Property Location/Ad ress 44-. 5 Perf. j►) _. . ve o v P -15 <br /> i Property Owner Nei)i) C 11 �_ Address Pn- . 174 5._A¢ <br /> -Operator's Name _5165/ C74 Address .0'-S.0 I _ 9¢- 4L <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating 68pacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIOUOR 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 D <br /> 3. WATER aUALITY ❑ 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. ❑ CONSULTArON FEE --------.--- <br /> 7. ❑ PLAN CHECKING FEE — -- <br /> 8. REAL ESTATE <br /> REQUEST Water Well Inspection[] Sample❑ Title Company <br /> Sewage System Inspection Cl 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 regul ions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE Xt _ 1` . Title. P Date ` <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALt Y ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 R Received By January 31 ❑ July 1 d Received By July 31 <br /> 1 BILLING REMITTANCE S REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION --.-�– <br /> t <br /> PLUS <br /> PENALTY <br /> OTHER I <br /> OTHER <br /> Receweo by Date Receipt No Permit No issuance Date Mailed Delivered k <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA <br />