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Applications Will Be Pr ed When Submitted Properly Completed. Be S► Sign The Application. <br /> f APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONS N <br /> - -- ---- — <br /> 1 ENSE AND/OR POULTRY RANCHES AND KENNELS <br /> iTRATION MISCELLANEOUS SERVICES Re 0. <br /> I. .BER C—.__._.___.___..___.._.-._. .__-- <br /> rApplication Date__ Business/Name To Appear On Permit _-_ __. <br /> FTYpe Permit/Service Requested:-. --__._— <br /> a Applicant Name___C-7 L_QfSt.O_CISt011 Address -_-425-_N-,---�__DDr-ado,-StoCkton 9 -02 <br /> U <br /> a---- ----..=—.-__-- -___ Business Telephone No. _____.._-__.__ _ Emergency Telephone No. -- <br /> It Property Location/Address___-AUStin--Rd ,-$_tOCkt017---__-_-._._._-.._..__-.-_.- ___-____.-_—____—_ <br /> ------ -- <br /> Property Owner <br /> Address - ---------- — - <br /> LOperator's Name __—__-_ _-__--_ Address --- <br /> 1. <br /> ddress _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 5TedrPermit Review <br /> 7. ❑ PLAN CHECKING 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 ______-- 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 /> APPLICANT'S SIGNATURE X _ Title __ Date <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE _DATE REMITTED AMOUNT_ <br /> FEE 10_5_0.00 See Att_a_ch dL5L29/90 <br /> $1050.00 <br /> LESS -- <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER ii 11"1 _':L �.. ;.� a — <br /> OTHER <br /> Received by Date Receipt No Permit No Issw nce Date Mailed Delivered <br /> — APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Gox 2009 STOCKTON,CA 95201 <br />