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r <br /> ' Applications Will Be Pry/ 'sed When Submitted Properly Completed. Be &^ 'o Sign The Application. <br /> APPLICATION ,� SFp a A Igo <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEERS 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 /> IrIENSE AND/OR POULTRY RANCHES AND KENNELS Regist. NO <br /> STRATION MISCELLANEOUS SERVICES <br /> I. Color <br /> .BER <br /> Application Date�'�'v v Business/Name To Appear On Permit - - <br /> oType Permit/Service Requested: _ --- --.c-r-�- --- <br /> Appli nt Name '1. Sy-� Address ✓� A Wet&L C <br /> __ Bu iness Tel�epehone No. Emergency Telephone No. <br /> IL <br /> Location/Address. <br /> �� F 1 NFA Z <br /> I <br /> Property Owner Address -- <br /> -(Operator's Name A& Address <br /> 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 -ALL APPLICANTS: Total Employees Including Operators - <br /> 2. HOUSING p <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCYREc MEN <br /> 11 MOBILE HOME PARK/No. of Spaces F/ V Fo <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL OC <br /> ❑ PUBLIC WATER SYSTEM 13 SURFACE WATER SUPPLY ❑ WATER HAULER �N� / 6 J� <br /> N0, OF PUBLIC SERVED (Connections) �RO/�/ - <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING SEREIVjgC <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds - T7SER //C rfiq�Tc' <br /> F :ENNEL/Runways - /Animal Population No. No. of Confining Cages ,7 <br /> Sewage Disposal Method - <br /> Solid Waste Disposal Method <br /> Water Supply Source _ Anl,Wate-D\sisposal Method <br /> 6. CONSULTATION FEE f�" <br /> / <br /> 7. U 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 /> APPLICANT'S SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 S Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> ,�y� DATE DATE REMITTED AMOUN _ <br /> FEE r(l(/ (11K, Q 60 <br /> LESS <br /> PRORATION <br /> PENALTY PENALTIES ILL BE APPLI D <br /> OG DA <br /> OTHER <br /> E, <br /> OTHER �i <br /> ived by D Date ipt No. Permit No. IWU late Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVI)eMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZNft4N AVE.,P.O.Baa 2009 STOCKTON,CA 95201 <br />