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.v .n -TRW+ v: <br /> Applications Will Be Proc When Submitted Properly Completed. Be Sureoign The Application. <br /> 1 • APPLICATION <br /> tNVIRONMENTAL HEALTH PERMIT/SERVICES <br /> INEER'S AND/OR Y IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR ° FOOD ESTABLISHMENTS,HOUSING =ate <br /> CONTRACTOR AND/OR ?l.�r'-' OilPUBLIC POOLS.WATER SAMPLING Make — _—__— <br /> BROKER AND/OR REAL ESTATE INSPECTIONS LIC No. <br /> ir'ENSE AND/OR '•'" POULTRY RANCHES AND KE;IINELS\ <br /> 3TRATlON MISCELLANEOUS SERVICf$f RegySt:,NO. <br /> i. BER ,`, �... <br /> -- �. 3� Color <br /> t a <br /> -Application Date 81� 'riess)au `e Tppear in Permit <br /> F Type Permit/' Re uestec <br /> a Applicant Nam r add 1337 <br /> s <br /> r -11 <br /> _ - '�r usiness T :lephone Nor Emergency Telephone No. <br /> It Property Location/Address _Z112- Or r <br /> aProperty Owner ; 4r • Address 4"h li <br /> LOperator's.Narr ' .x� Address <br /> 1. FOOD ESTABLISHMENTS Total BuildinSq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT'' •r C3FOOD MARKET RETAIL , ,:I ❑ F08"A;4 t1VH0LESALE ❑ MEAT MARKETI'4,' 44, <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 13 WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds - <br /> r :ENNEL/Runways _--__. /Animal Population No. t No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water ply Source _ _ _ Animal Waste Disposal Method <br /> 6. NSULTATION FEE <br /> 7. -PLAN CHWCKING 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 - � _ - ,T_: = SelterAddres5 f '' <br /> Telephone No. Seller Agent Name <br /> Service Request For Date — — <br /> r: <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 /> APPLICANT'S SIGNATURE X _ Title Date <br /> i <br /> r Sj FOR DEPARTMENT USE ONLY <br /> Feels Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH .❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> RNG REMITTANCE .$ REMIT '.+ <br /> BASE EXPLANATION AMOUNT DUE C ECKED <br /> TYATE DATE REMITTED MO NT <br /> FIEE �D t 8/21/90 <br />: ! <br /> ° --LESS <br /> - <br /> PRORATION <br /> i , <br /> F <br />°f PLUS. _ - _._. ._. r, <br />!�. PENALTY - - - <br /> I OTHER <br /> OTHER <br /> Received by Date wpt No. Permit No. issu,11W4te Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE: P.O.SOX 2009 STOCKTON C"5201' :' <br />