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Applications Will Be Prc 'sed When Submitted Properly Completed. Be Sup- To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINE y'S AND/OR IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR E000 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 /> STRATION MISCELLANEOUS SERVICES <br /> I. .SER c Color <br /> (Application Date — /,r-/ V5 y-i. Business/Name To Appear On Permit I-A F R-� V31,U ~� <br /> oType Permit/Service Requested* <br /> ApJjplicant Name -A r &11 s.._. T...� yAddress f u M6 2✓ la <br /> I A (7A 9007/ %usinep Telephone No. 7 a 9 ' J OYmergency Telephone No. <br /> e Property Location/Address 0 (3C9'•R I�C�IV 1 tJ <br /> Property Owner t' I' Address u4� OL /90 . 1- /1 <br /> 10perator's Name Address t CCu. 6 0 O� <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant? axim 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- - -aFOOG-SALVAGER- FOOD DEMONSTRATION-=:_ ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators _ _. PAYMENT <br /> 2. HOUSING RECEIVED <br /> ❑ HOTEL/MOTEL/No.of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces AUG 2 ,r, 1983 <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER ENVIRONMENTAL HEALTH <br /> NO. OF PUBLIC SERVED (Connections) &ERMITISERVICES <br /> 4. RECREATIONAL HEALTH D SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLA <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 /> Wat r Supply Source Animal Waste Disposal Method <br /> 6. CONSULTATION FEE I `err <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection Sample❑ Title Company <br /> Sewage SystAn Inspection ❑ Address Tele. No. <br /> Escrow No. - <br /> - Sauer --_ _ _ - - Seller Address - <br /> Telephone No. Seller Agent Name <br /> Service Request For Date <br /> I hereby certify that I have prepar <br /> ad this a It ti and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a d rules and regul Ion f'the San Joaquin Local Health District. - <br /> APPLICANT'S SIGNATURE X L Title If vi-' Date / 7 �� - <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 /> DATE DATE RE ED AMOUNT_ <br /> �r <br /> FEE �7-1• G <br /> oN Ja 5 (see att ched) <br /> PLUS <br /> PENALTY <br /> OTHER 3D 6/1/88 DU IMMEDIATE Y <br /> OTHER <br /> Received by Date �, ,.,pl No. Permit NoData Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 20011 STOCKTON.CA 95201 / <br />