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Applications Will Bessed When Submitted Properly Completed. Be To Sign The Application. <br /> V <br /> ` Ij �, <br /> APPLICATION 0 , <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES j /j.' <br /> ENGINEER'S AND/OR 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 /> IrENSE AND/OR POULTRY RANCHES AND KENNELS Regist. NO. <br /> 3TRATION MISCELLANEOUS SERVICES 9 <br /> I, .BER Color <br /> [Application Date Business/Name To Appear On Permit <br /> : <br /> Type Permit/Service Re Lasted: <br /> a Applicant Name %EMCO Address 431 W. Hatch, Modesto 95361 <br /> U <br /> Business Telephone No. Emergency Telephone No, <br /> 425 N Union Rd. Stkn <br /> a Property Location/Address s - <br /> aProperty Owner Address <br /> -I 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 VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees PAYMENT <br /> ALL APPLICANTS: Total Employees Including Operators RECEIVED <br /> 2. HOUSING pppp <br /> 11HOTEL/MOTEL/No. of Units 13 CERTIFICATE OF OCCUPAa�RR 2 3 `1990 <br /> ❑ MOBILE HOME PARK/No. of Spaces SAN JOAQUIN COUNTY <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL PUBLIC HEALTH SERVICES <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER ENVIRONMENTAL HEALTH DIVISION <br /> NO. OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. 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 /> S. ❑ CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE <br /> B. 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 tha I av prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state I s ai rules d e ulatio sof th San Joaquin Local Heal h District. <br /> APPLICANT'S SIGNATURE R Title Date O <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 Recei y January 31 ❑ July 1 8 Received By July 3t <br /> BABE EXPLANATION BILLING REMITTANCE $ MOUNT;OUE CHECKED REMIT <br /> DATE DATE REMITT A OUNT <br /> FEE $35.00 In pection 4/5/90 j$35A0 <br /> LESS <br /> PRORATION <br /> PLUS L BE AP LIED TO PAS r DUE <br /> PENALTY ACCO NTS <br /> OTHER <br /> OTHER <br /> Received by — Date Opt No. Permit No lad ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo,2009 STOCKTON,CA 95201— <br />