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/ a <br /> Applications Will Be Processed when Su APPLIProperly CATION Completed, Be Sure=n Sign The Application. <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES IF VEHICLE INVOLVED, GIVE <br /> ENGINEERS AND/OR F000 ESTABLISHMENTS,HOUSING Make <br /> _ APPLICANT'S AND/OR PUBLIC POOLS.WATER SAMPLING <br /> CONTRACTOR ANO/OR REAL ESTATE INSPECTIONS LIC. NO. <br /> BROKER AND/OR POULTRY RANCHES AND KENNELS Reglst. NO. <br /> 10ENSE AND/OR MISCELLANEOUS SERVICES <br /> 3TRATION Color <br /> I, .BER <br /> f Application Date ��`T-� Business/Name To Appear On Permit <br /> Type Permit/Service Requested: ^ t:'Dun�v It CLwh GI-✓D <br /> Address <br /> Applicant Neme g yZ /!7 Emergency Telephone No.yIC-62S--?,V4 <br /> Business Telephone uj <br /> Property Location/Address <br /> Address <br /> Property Owner Address <br /> Operator's Name <br /> um Sealing Capacityim <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Seating <br /> MARKET <br /> ❑ RESTAURANT 13 FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE <br /> ❑ COMMISSARY ❑ ICE PLANT 11BAKERY <br /> 13 FOOD PROCESSING PLANT ❑ BAR 13 ITINERANT RESTAURANT <br /> 13 ROADSIDE FOOD STAND ❑ LIQUOR STORE 11 FOOD VENDOR <br /> ❑ CONFECTIONARY STORE 11 FOOD SALVAGER 11 FOOD DEMONSTRATION <br /> ❑ VENDING MACHINES/No.of ❑ MOBILE FOOD PREP. UNIT O VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No.of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ HOTEVMOTEL/No. of Units <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY 11 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 /> 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 /> Animal Waste Disposal Method <br /> Water Supply Source <br /> 6, CONSULTATION F S I TQ'Y 1�- ---?Lo� �TQCgT&,j <br /> 7. ❑ PLAN CHECKING FEE <br /> S. 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, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANTS SIGNATURE X Title Date 2-y <br /> 0,9 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 9 Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> IL <br /> BASE EXPLANATION BLING REMITTANCE $ AMOUNT DUE CHECKED <br /> �f DATE DATE REMITTED AMOUNT_ <br /> FEELESS <br /> / 5 <br /> PRORATION <br /> PLUS <br /> PENALTY -- <br /> OTHER <br /> OTHER qq, <br /> L � <br /> by Daiie j'pt No. Permit No. lass. A1ata Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRMENTAL HEALTH PERMIT/SERVICES 1601 E.KAZELTON AVE.,P.O.boa 10M STOCKTON.CA 95201 <br />