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Applications Will Be ssed When Submitted Properly Completed. BeTo Sign The Application. <br /> APPLICATION 0 <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING C 'r, <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING G% Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONS PA�,�Et�. No. <br /> DENSE AND/OR POULTRY RANCHES AND KENNELS VRenist. No <br /> 3TRATION MISCELLANEOUS SERVICES �r�p ---- ---- ---- <br /> I. .BER - -------- _.. + 1 r <br /> �,�,t/u��Ty 5 <br /> ('Application Date- ___— Business/Name To Appear On Permit .____- __ SA1�A��t <br /> ,AType Permit/Service Requested: <br /> u Applicant Name- Austl n Rd - City 146�y of Stockton address _ �p0 ,`'Stkn 95206 <br /> a <br /> -__ _— _--—__—___ _ Business Telephone No._.______._.._— _—__—_ Emergency Telephone No. <br /> IL Property Location/Address- Austin Rd. , Stockton <br /> <Property Owner Address <br /> Operator's Name _—.—.__—__ 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 VEHICL,C,, .1 <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators— _ ___ � �> <br /> 2. HOUSING 9C, <br /> 11 <br /> ❑ MOBELE HOME/PARK/No.No. of ltof S aces ❑ CERTIFICATE OF OCCUPAN6 Y �`�,��CF`���� � <br /> P <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL p Off ' <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULERo��80 + <br /> NO. OF PUBLIC SERVED (Connections) _ __ _ _ ".• o9 �4 Mfr `err <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACEr <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> .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 Solid Waste <br /> 7. ❑ PLAN CHECKING FEE -- _ <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection Sample Title Company <br /> Sewage System Inspection Cl Address _ ..__ _Tele. No. <br /> Escrow No. <br /> Seller _ _ ____________---__ Seller Address <br /> Telephone No. Seller Agent Name <br /> Service Request 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. l VmurZ S <br /> APPLICANT'S SIGNATURE X _ ` Title—D1,'-Lc7f�e <_lk C&I(Date Z l L� <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT i <br /> FEE p 1qn 665.00 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> C _ V-) <br /> Received by Date Receipt No. Permit No Issuence Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 •---- <br />