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Applications Will Be P SC <br /> Ed When Submitted Properly Completed. Be o Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> .DENSE AND/OR POULTRY RANCHES ANDKENNELS Regist. No. <br /> ;TRATION ��oZ� MISCELLANEOUS SERVICES <br /> I. .dER �g Color 1 <br /> (Application Date_I��Z�—i�q Business/Name To Appear On Permit Yv � (l�0`�i✓1� 0 �11N <br /> oType Permit/Service Requested: S6/L 3DjZltJKo <br /> <Applicant Name CW-1W E61k-fit T�Ctf7 ou tiles !NCI Address CO W' 00-C< <br /> U _ <br /> Business Telephone No. Emergency Telephone No. <br /> .Property Location/Address 107 N- �oL 6D 1 64, lea,Yw <br /> -iPropertyOwner R ' NQS tF_ M� hIUE�lE�D Address O 3d �OdDB� �>C <br /> AOperator's Name INV it- 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 /> S. 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 /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE sp/� 'gdR(FIG �CCdSUQ 1MS(�FsTTa�'� <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 /> lland <br /> d rules and regulations of the San Joaquin Local Health District. J�Q <br /> APPLICANT'S SIGNATURE X 11�+^ j7Title ����f�� Date t111��`U 1 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 d Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <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 9S2011 <br />