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A' . <br /> r Applications Will Be P ssed When Submitted Properly Completed. Be .To Sign The ApplicaUo ..._ <br /> , ., APPLICATION ; <br /> ' ' ` ,. ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> GINEER'S AND/ IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make <br /> " CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING —�--_ -_ <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic.No. <br /> Ir^ENSE AND/OR POULTRY RANCHES AND KENNELS Regist. No.- <br /> 3TRATION MISCELLANEOUS SERVICES 9 ------ <br /> I, aER ----------- -.-— Color -_ <br /> "Application Date Business/Name To Appear On Permit <br /> fnType Permit/Service Requested: <br /> Applicant Name Austin Rd - City of Stockton Address_1465 S L nco n, . t n 95206 <br /> iiBusiness Telephone No. } Emergency Telephone No. • <br /> 'a Property Location/Address. <br /> Aust n Rd. ItStockton <br /> 1Property Owner Address i <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 ems; <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY • <br /> ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> 01RE STORE ❑ FOOD SALVAGER ❑ FOOD DEMQNSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field EmployeesALL 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 Q, 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 Solid Waste <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 /> I Seller Seller Address <br /> yTelephone No. Seller Agent Name7. <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 /> V^ {u �U�IGpS <br /> 6_1 <br /> APPLICANT'S SIGNA, E X4 4, F :. �.,..t.Title7.: '�i Cy ate <br /> ne <br /> FOR DEPARTMENT S,EQTY, it"r <br /> `> .. 1. r <br /> Fee is Due: C] ANNUALLY ❑ PER UNIT C1 PER SITE El EACH [],.January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REM&TANCE $ <br /> BASE' EXPLANATION AMOUNT DUE CHECKED <br /> g DATE DATE REMITTED AMOUNT <br /> ' F8E � <br /> t 665.00 <br /> LESS i - <br /> 'PRORA710N <br /> PLUS <br /> PENALTY, <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 --J <br /> r' <br />