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v �N VIRONMENTAL HEALTH PERMIT/SEF Y V <br /> ENGINEER'S AND,OR Ii IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND:OR I: FOOD ESTABLISHMENTS.HOUSING Make <br /> CONTRACTOR AND OR PUBLIC P0111.3.WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lit- No <br /> irENSE AND(OR I POULTRY RANCHES AND KENNELS Regist. No <br /> 3TRATION MISCELLANEOUS SERYIC_S - --" <br /> 1. .dER - -. Color --- <br /> i, <br /> 7 0 <br /> iApplication Date c�`caCBusiness/Name To Appear On Permit J�✓C�O�1�_- C7 -�._...____..._—�_—_--_ _. <br /> ,n Type <br /> Permit/Service Req9ue�st�ed <br /> f � T �r=.2 <br /> Applicant Name C7 EL �/ Ek'E�/r12_ . I�Address <br /> 1Q����'. .-9///1y`�_•1�•_/�_'�9'-_/�l_E!�S_Y.�/d��•r� <br /> Telephone No-4 ...T.✓�� Emergency Telephone No. <br /> Property Location/Address15s/ rr�.� Vii(!--._✓J�/�c ---.—A '—/._..�.!j�cYl �J//_- � <br /> �Operalvr`s Name ..._...�! EAddressr /�'• _c ��I�� �f� .—. s�- <br /> 1 Property Owner l�yil9�.f/U�yl Vim'!!!_ Q�.- _ <br /> 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 It ❑ 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 _______......_......�i _ ❑ MOBILE FOOD PREP.. UNIT ❑ VENDING V <br /> I] FOOD CROP HARVESTING/No. of Field Employees'� <br /> ALL APPLICANTS: Total Employees Including D <br /> 2. HOUSING !r <br /> ❑ HOTEL/MOTEL/No, of Units ._. _.._ _____-. ❑ CERTIFICATE OF CC Y1 ai <br /> ❑ MOBILE HOME PARK/No. of Spaces A `�a� <br /> 3. WATER OUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER' - ENVY PERMIT <br /> I ERV HEALTH <br /> f IrI�MIT 1 SERVICES <br /> NO. OF PUBLIC SERVED (Connections) .._-_-- ..._.._....4._____. <br /> 4. RECREATIONAL HEALTH ❑ SWIMb'ING POOL ❑ SPA ❑ WADING POOL ❑.NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. Of Birds <br /> '.ENNEL/Runways h <br /> /Animal Population No. _ _i No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method_- <br /> W%Supply Source -- `:--- - I <br /> Animal Waste Disposal Method <br /> 8. CONSULTATION FEE <br /> 7. © PLAN CHECKING FEE — ° - —• (�_ <br /> 8. REAL ESTATE y - - <br /> REQUEST: Water Well Inspection❑ Sample[] ! # <br /> Title Company .. <br /> Sewage System Inspection ❑ �� <br /> Address <br /> Escrow No. ______ Tele. No. <br /> - .i .. _._ . <br /> Seller Seller Address <br /> Telephone No. ---.---. _.--.--__ - _ Seller Agent Name'i — <br /> Service Request For Date <br /> k <br /> I hereby certify that I have prepared this application and that€the work will be done in accordance with San Joaquin County <br /> nrdtnanra¢ elate laws and <br /> MAN EL V. SANTOS <br /> JOE F. SANTOS. JR. .i ' 216 <br /> EDW V. SANTOS li <br /> EULALIA M. SOLARI <br /> 6748 N. PERSHING <br /> 90-103 <br /> f f <br /> STQCKTON, CA 95207 19 �!3 1211 <br /> PAYTO THE <br /> ORDER <br /> d 4 <br /> LLARS <br /> B NK STOCKT4N <br /> CARSON OAKS OFFICE ! <br /> 6808 Pacific Ave.,Stockton,CA 95207 <br /> FOR <br /> 1110002161f' 1: 1211010371:- 22- 21, 2SLL11•0L <br />