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Applications Will Be F ;sed 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 /> APPLICANTS AND/OR FOOD ESTABLISHMENTS.MOUSING Make - _NIA <br /> CONTRACTOR ANO/OR PUBLIC POOLS.WATER SAMPLING �l� <br /> BROKER ANO/OR REAL ESTATE INSPECTIONS Lic. No. - <br /> .IrENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No.�`� <br /> I. .8ER , Color N/4 <br /> JI <br /> iApplication Date �J3 ' 0 Business/Name To Appear On Permit A On a (r- UR} d __ <br /> u,Type Permit/Service Requested: <br /> Applicant Name H4 y`rnSP/1 4,. 4ZL16& Z,,..v��d.•�.a-A16Xddr6SS 3 <br /> J x20 - _ Business Telephone No' �1 L6 �3K L C23 Emergency Telephone No. r�f IC 7E2 3� T <br /> IL <br /> i Property Location/Address D <br /> 'iProperty Owner Address <br /> Operator's Name * H% Address (--6­T,_-,6,_,,164,�e� !12t �i K jq 7-3 Y? I.,, O <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 N/111 ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees ���V``� <br /> ALL APPLICANTS: Total Employees Including Operators IV1A <br /> 2. HOUSING <br /> ❑ HOTEUMOTEUNo. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces A11A - <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) NX0!1 <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL /��❑ POULTRY FARM/Maximum No. of Birds 111A <br /> r :ENNEURunways _L1�`J—_ /Animal Population No. n7�� No. of Confining Cages NZ-4 <br /> Sewage Disposal Method &AI - <br /> Solid Waste Disposal Method 1018 — <br /> Water Supply Source IV 1A Animal Waste Disposal Method <br /> 6. U CONSULTATION FEE ( 1,&Vj <br /> 7. PLAN CHECKING FEE <br /> B. REAL ESTATE / / /` <br /> REQUEST: 1A Mw Welt Inspection Sample[] Title Company /V/, <br /> Sewage System Inspection ❑ Address Tele. No. <br /> Escrow No. <br /> Seller /U!A Seller Address NIA <br /> Telephone No. 1 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. 0f <br /> APPLICANT'S SIGNATURE X ��)6_a Title ate L'_3_ I o <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> z DATE DATE REMITTED AMOUNT <br /> FEE ZJrC�/ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> r <br /> OTHER <br /> OTHER <br /> J <br /> Rer P,veo by Date Receipt No Permit No Issuance Date Matted Deovered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT,SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />