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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> r <br /> APPLICATION <br /> '*AVIRONMENTAL HEALTH PERMIT/SERV%�ES <br /> ENGINEER-S AN[)OR IF VEHICLE INVOLVED, GIVE <br /> APPUCANT 5 AND.OR FOOD ESTABLISHMENTS.HOUSING Make <br /> CONTRACTOR ANO:OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND OR REAL ESTATE INSPECTIONS Lic. No. <br /> .rENSE AN&OR POULTRY RANCHES AND KENNELS Reg ist. No. <br /> STRATION MISCELLANEOUS SERVICES <br /> Color <br /> -Application Date� 1� Business/Name To Appear On Permit kcXNF�` 1 _ <br /> ,aType Permlt;Service Requested: 5C / e, IU/NEwML X55 3.5MEnlT <br /> Applicant Name E �He Con-P6Jr� Address q7/ES- &a.CT IJF_SS ��R� �� Sac_,r m1,,, Ch <br /> U Business Telephone No, 3fn 1-1741 ex f32Z, Emergency Telephone No. <br /> CL <br /> Properly Location/Address e W-flito kolest T n /� <br /> pi E C; Tao tr�l r ea+, JJra�Jyte�r CA <br /> i Property Owner Z sl R.L ird.A, Laird,W,ft�c1,.d�.�1/.Mi e0 ddress -� <br /> Operator's Name Address ArJhni SQ &,,- 7o-11 b 1A),Vt Turw.0 <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 /> ❑ HOTEUMOTEL/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 /> S. 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. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <br /> Escrow No. <br /> Seller Seiler Address <br /> Telephone No. Seller Agent Name <br /> Service Request For Date <br /> I hereby certify that'l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances. state laws d rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X 0, Title Title ,E+ Co C-41'5ate <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION °BILLING REMITTANCE $ <br /> � AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> - <br /> r �S <br /> r;CPA'ION <br /> �L_S i <br /> P�`JA L'V <br /> OTnER <br /> I <br /> C7HER <br /> I <br /> i <br /> aece,ea by Date Receipt No Perm.i No Issuance Date Mailed Delivered ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT SERVICES 1601 E-HAZELTON AVE..P.O.9o■2009 STOCKTON•CA 95201 <br />