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i <br /> Applicatlens WIII B ceased When Submitted Properly Completed. *re To Sign The Application. <br /> APPLICATION <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 /> .IrENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Reg ist. No.-----, <br /> I. AER _ b Color <br /> [Application Date av;e ness/Name To Appgggar Per�it <br /> mType Permit/Service R quest L.s°1?� �2 <br /> r <br /> U Applicant Name �l 011lid-.h-��y_c�_en Address_/_.{/.,_��`fes/ 99-� GQ <4.vt) <br /> u _ Business Telephone No..��../Sy "�i.11D EmergAncy Telephone No. <br /> 'a Property Location/Address- �1 V""a�� `` ��, SGa��` <br /> a Property Owner_&& le `�3i lrzw/ i14 Address <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 /> 1 ❑ GONFEGTIONARY S'rOAF ❑ FOOD CSLVnGrR ❑ FOO ❑ cpnn vcn,nno <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 <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 ❑ NAT ATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> --C :ENNEURunways /Animal Population No. No. of Confining <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water T�Supoly Source Animal Waste D' pos�l Method <br /> 6. Ma" bONSULTATION FEE e <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 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 regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 8 Received By July 31 <br /> ,jAj1� REMIT <br /> BASE EXPLANATION B <br /> ]TION OATE R�DA '1EY ��1FEM TTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> , <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY PF AMEsvAEE <br /> E n <br /> OTHERbA S'FROM B16 I E-APPLILL) 10P Ifs 30 <br /> OTHER <br /> 5isaQ `-7 5 G <br /> Received cy Dale Receipt No. ermit No. Issuancfe Date Mailed Delbered <br /> ` APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 209 STOCKTON,CA 95301 <br />