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ENGI ER'S AND/OR <br />APPLICANT'S AND/OR <br />CONTRACTOR AND/OR <br />BROKER ANWOR <br />irENSE AND/OR <br />3TRATION <br />1. .BER <br />ENVIRONMENTAL HEALTH PERMIT/SERVI <br />OP <br />FOOD ESTABLISHMENTS. HOUSING <br />PUBLIC POOLS. WATER SAMPLING <br />REAL ESTATE INSPECTIONS <br />POULTRY RANCHES AND KENNELS <br />MISCELLANEOUS SERVICES <br />IF VEHICLE INVOLVED, GIVE <br />Make ---- ----- -- <br />Lic. NO. —------- --- <br />Regist. No. - ---- ------ - <br />Color ----..------ — . <br />usiness/Name o Appear On rmit'i. <br />{ Application Date -- -- --- -- ---- <br />�Type Permit/Ser ' Requested: <br /><APPlicant Nam __ --___-----_.._ —( /---- Aless <br />!N <br />Ines Telephone NEmergency Telephone No. <br />;SWProperty Location/ ddress --- — <br />Property Owner _— --_-_ Address — <br />it <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 />❑ 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/MOTEUNo. of Units ❑CERTIFICATE OF OCCUPANCY <br />❑ MOBILE HOME PARK/No. of Spaces <br />3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL t <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 />S. 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 />Animal Waste Disposal Method <br />Water Supply Source <br />6. ® CONSULTATION FEE a <br />7. PLAN CHECKING FEE <br />8. REAL ESTATE <br />REQUEST: Water Well Inspection C3 Sample❑ Title Company <br />Sewage System Inspection ❑ Address —____ _ Tele. No. <br />Escrow No. _ Seller Seller _.____ _ — Seller Address _— hone No. — <br />Telephone Seller Agent Name <br />- ----------------_--- <br />Service Request For Date ------- -- --- - -- — --------- __ <br />1 hereby certify that 1 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 -. ^'�'^-"-� <br />�,� - .__ Title _V_0�7 ------ Date <br />FOR DEPARTMENT USE ONLY <br />n n cw I_1 I.., t A Received By January 31 ❑ July 1 S Received By July 31 <br />ree Is UUe. u ANNUMLI.-- <br />REMIT <br />BILLING <br />REMITTANCE ! <br />$ <br />AMOUNT DUE <br />CHECKED <br />BASE <br />EXPLANATION <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />p <br />_17— <br />FEE <br />/ <br />LESS <br />PRORATION <br />—_ <br />PLUS <br />PENALTY <br />_— <br />— <br />OTHER <br />OTHER <br />9/ by Date Receipt No. Permit No. Issuance MtN1ed ueuvereu <br />APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 4601 E. NAZELTON AVE.. P.O. Bo: 2009 STOCKTON. CA 91201 <br />