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Applications Wllf Be Pr, used When Submitted Properly Completed. Be St, 'o Sign The Applicatlo <br /> APPLICATION - 7A <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEERS AND OR IF VEHICLE INVOLVED,GIVE <br /> !ePLICANT S AND,OR FOOD ESTABLISHMENTS.HOUSING Make <br /> CONTRACTOR ANCLOR PUBLIC POOLS.WATER SAMPLING <br /> BROKER AND.'OR REAL ESTATE INSPECTIONS LIc. NO. <br /> DENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES 1. <br /> Regist. No. __.. <br /> I. 11511 __.. ISIti \/ w 111Color <br /> f Application Date __ _____.__ Business/Name To Appear On Permit _ <br /> Type Permit/Service TREe7�uueesstted: __. <br /> BERGISM <br /> i APPlicangt� """-,- . __ _... Address 4900 WAREHDuSE-.4jAY 10 <br /> '"`"�� �. 95$26_ Business Telephone No (91-61387-0198_-__ Emergency Telephone No. <br /> - _—_ <br /> '. roperty location/Address 501E W _ _ _ —_ _._. _ -- <br /> _iPro'Property <br /> perty Owner _._.__ - _ _ _ - Address <br /> 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 <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units _._____._—. ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY ❑ 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 /> Water Supply Source Animal Waste Disposal Method <br /> 6. ❑ CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE — <br /> 6. REAL ESTATE <br /> REOUEST: 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 /> 1 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 Out: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 18 Received By January 31 ❑ July 1 6 Received By July 31 <br /> i <br /> BILLING REMITTANCE $ REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE $35 inspection 12-12-90 <br /> LESS --_ -- -- - <br /> PRORATION <br /> PENS <br /> PENALTY $3 50 pertallty1 25-91 $38,50 <br /> OTHER - — <br /> nece,vM by Oale ReteiPl No Permit No Issuance Dele Mailed Deliveratl <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES last E.HALELTON AVE.,P.O.Be.IaIM STOCKTON.CA 952111 <br />