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• Applications Will Be P"-essed When Submitted Properly Completed. Be?" To Sign The Application. <br /> .,,,1111,r APPLICATION ��rr <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,MOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING -- <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> IrFNSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION 2 MISCELLANEOUS SERVICES Regist. No. <br /> I, .BER R4(Q��7J ,Zzr-� Color -----.-- <br /> Application <br /> olor — -Application Date 1f^ 7-3`�_ - ___ Business/Name To Appear On Permit 1LV7[I .N�� _ � ��N <br /> yType Permit/Service Requested: _SOIL 3DZ__N.62-- <br /> uApplicant Name Cw1w 1: t69- 061F�ING.r_ _ Address Z0OW_ <br /> ., —_ _ —.._ . Business Telephone No. /C9,0(Zq Emergency Telephone No.— <br /> aProperty Location/Address 107 10-,- 1 '* <br /> `Property Owner_Tx ' RD VDKI—_�/''l� 9VE�AE_ � �_— .. Address r1 36K D 1J01f�-$� r :k _._ <br /> -,Operator's Name . 9/117. __.. —. -- __.._. _.. _..— .. 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/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 /> r :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 /> T. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE Soli, 3olU96 (c4o5U&_jw5QFs176k) <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, <br /> and <br /> drrules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X -_lL—"�r`"�1 E%�✓` ._ _.__ Title_6-ro("J7�- Date tm�` <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> I -- ------ -- REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> t AMOUNT <br /> FEE- -- <br /> _ t. <br /> LESS <br /> PRORATION <br /> PLUS ------ — - ---- -— _ -- - <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />