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Appli&tions Will Be Pr sed When Submitted Properly Completed. Be S o Sign The Application. APPLICATION ENVIRONMENTAL HEALTH PERMIT/SERVICES ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. .irENSE AND/OR POULTRY RANCHES AND KENNELS 3TRATION MISCELLANEOUS SERVICES Regist. No..__.___--__._._...__--_________ I. aER ___---------------__..__ Color Application Date_—_--____ _—______ Business/Name To Appear On Permit ,hTYpe Permit/Service Requested:------------- - -- - - -- -.- - --- -- ----- -- ---------- - i Applicant Name _—Sa-n--�JOaqu!n-C"n-ty--Dept.--P-ubl-1 C---Wolk 1�ess_-__P..--0--Box -1$1D,—Stkl1--952D- ------------------- U A_ _.._____________--__—_ ._ Business Telephone No._.._—_____—_____—.—_ Emergency Telephone No. _ —_— a Property Location/Address 4 Property Owner _--_-- ------- ---_-_._ Address ----__---__--- --___—- Operator's Name _.______-- _ —_____—__ Address 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR ❑ VENDING MACHINES/No. of _ ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE ❑ FOOD CROP HARVESTING/No. of Field Employees ALL APPLICANTS: Total Employees Including Operators y 2. HOUSING ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY ❑ MOBILE HOME PARK/No. of Spaces 3. WATER OUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER NO. OF PUBLIC SERVED (Connections) 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds-----__ .ENNEL/Runways _— /Animal Population No. — No.of Confining Cages Sewage Disposal Method Solid Waste Disposal Method _ Water Supply Source _._ Animal Waste Disposal Method 6. ❑ CONSULTATION FEE 7. ❑ PLAN CHECKING FEE — 8. REAL ESTATE REQUEST: Water Well Inspection Sample[] Title Company Sewage System Inspection ❑ Address _..__ Tele. No. Escrow No. ------- — Seller—`—_ Seller Address Telephone No.___— _— Seller Agent Name Service Request For Date ------_.--_--_-------__---_______._.. I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws. APPLICANT'S SIGNATURE X ____..— Title—_ Date FOR DEPARTMENT USE ONLY Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED —__ AMOUNT FEE $665.00 see at ch d8/24 90 $665.00 LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. Issuance Date — Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201