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/ <br /> c <br /> Applications Will Be Processed When Submitted Property Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> ENGINEERS AND/OR EI RONMENTAL HEALTH PERMIT/SERVIL^3 <br /> APPLICANT'S AND,OR FOOD ESTABLISHMENTS,HOUSING IF VEHICLE INVOLVED,GIVE - <br /> CONTRACrOR AND/OR - PURLIC POOLS,WATER SAMPLING Make <br /> BROKEN ANDeOR REAL ESTATE INSPECTIONS Lic.No. <br /> ICFNSE ANp/OR POULTRY RANCHES AND KENNELS <br /> D:S', �aTION MISCELLANEOUS SERVICES Regist.No. <br /> -- Color <br /> fAppiicttion Dale1 � �� _5m,%A- <br /> 1 -----_--i--,._ Business/Name To On Permit A <br /> v Type Permit/Service Requested:�, t- KCctitJa <br /> `Applicant Name W. �t�s!C �o r a,Il tt,,.,._rIJ <br /> O _ Address_ajQ n+Aih <br /> a Business Telephone <br /> S--fNo.( ff'8n'T_gQ2 Eme <br /> Property Location/Address rgency Telephone No(-kg) r • ��- <br /> Properly Owner AddressLt+,._cSQ_JS_E <br /> -[Operator's Name <br /> Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq.Footage Restaurant,Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET W- -� 1 MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMM--- ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIOUO ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/No.of ❑ VENDING VEHICLE <br /> ALLFOOD CROP HARVESTING/No.of Field Em 1- <br /> ALL APPLICANTS: Total Employees Including <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No.of Units <br /> 7CUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces I <br /> 3. WATER QUALITY ❑ WATER SAMPLE i <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE: i <br /> NO.OF PUBLIC SERVED(Connections) f <br /> 4, RECREATIONAL HEALTH ❑ SWIMMING F ATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARfv �. <br /> w ENNEURunways /Animal Pol is <br /> S .i6ge Disposal Method I / <br /> Solid Waste Disposal Method <br /> Water Supply Source o - <br /> 6. CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE I <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ Sample[] <br /> Title Company <br /> Sewage System Inspection ❑ Address Tele.No. <br /> Escrow No. <br /> Seller Seller Address <br /> � . <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 /> ordinance,%state laws,and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANTS SIGNATURE X__E+� �4 ra_ Title i r Date <br /> FOR DEPARTMENT USE ONLY <br /> FCB IS Due:0 ANNUALLY PER UNIT ❑PER SITE ❑EACH ❑January t d Received By January 31 13 July 1 d Received By July 31 _ <br /> _- - DILLING-- ._._REMITTANCE-----_ . $-- _- -_-_._- ___-_REMIT_. <br /> _..- - <br /> ------- -- -- --— -BASE- --- EXPLANATION - AMOt3NT OUE CHECKED <br /> - - DATE DATE REMITTED AMOUNT <br /> FEE - ('� a <br /> LESS d .. <br /> PRORATION - - - <br /> PLUS - <br /> PENALFY - - <br /> OTHER <br /> OTHER <br /> Zo35 <br /> Received by Dale Receipt Na Permit No. Issuance Date Mailed Delivered ' <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1501 E.HAZELTON AVE.,P.O.Bo.20M STOCKTON.CA 95201 <br />