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Applications Will Be Proc-'-*',td When Submitted Properly Completed. Be Sure---"i Sign The Application. <br /> APPLICATION Ilij <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> (ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR _ F000 ESTABLISHMENTS.HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> LLrFIVSE AND/OR POULTRY RANCHES ANO_KENNELS Regist. No. <br /> rLecsTRATI MISCELLANEOUS SERYICFS <br /> rt�ERG 031606 Color <br /> (Application Date Business/Name To Appear On Per it - rot,�11)L�-1���_1_J'J�AI(�i i iKo-Not of - <br /> tChType Permit/Service Requested: 301�-V <br /> JQApplicant Name EPr �AlG11N �ll�1h .SC)ENf.I'� 1U0 Add ess 41A_ WALE� MLIZ I,AFR7V=tf65' PA !?6<49 <br /> 4%5 1S 3—loll <br /> l <br /> .a Business Telephone N Emergency Telephone N0.&A46532-fo37h <br /> a Property Location/Address iJ FI'(LS1411U1 VI . ON CA- <br /> 1 <br /> Owner Address A CA <br /> -Operator's Name WAD PAP.-.95 Address 56(a Nwj� p6mjlg6j -6rj Cil <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 t <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 <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 /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> .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. ❑ CONSULTATION FEE <br /> ,,7' EPLAN CHECKING FEE -- <br /> 8. REAL ESTATE i <br /> REQUEST: Water Well Inspection Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tele. No. f <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 arld regulations of the San Joaquin Local Health District. <br /> ,1� <br /> I'ARPLICANT'S SIGN_ ATURE:X cf IIVIItV){ Title WiRDNgt. At-- 941- Date `I <br /> FOR DEPARTMENT USE ONLY i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 19-EACH ❑ January 1 &Received By January 31 ❑ July 1 d Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT_ <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS �- <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Rved by r L Date Receipt No. Permit Na. Issuance Date Mailed Delivered <br /> PPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERV10ES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> {1~ <br />