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5 <br /> Applications Wil,' Be Prr ,d When Submitted Properly Completed. Be SI Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED,GIVE <br /> ESTABLISHMENTS.APPLICANT S AND/OR FOOD CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING .^ i„tir{ �= '� Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONSGE1v ED Lic. NO. <br /> IrENSE AND/OR POULTRY RANCHES AND KENNELS {v L Re 1st. No. <br /> 3TRATION MISCELLANEOUS SERVICES g <br /> I. .BER JAN 81991 Color <br /> [Application Date 12 /[�9c2 Business/Name To Appear On PermitcH�A)7F1 <br /> :Type Permit/Service Requested: ttip�� <br /> iApplicant Name —�V -✓Yli1 Bd�- ef'Tf /Address r-'i51 /-/� So)IL <br /> u EAy4�JLTTlo_�Q 9SR?Lo Business Telephone Nq. 9L,_KP���—b��_. <br /> `. -- � p_ —� Emergency Telephone NO. <br /> 'Property Location/Address -�C'"F��-7 i>le <br /> i Property 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 ❑ LIOUOR 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 DUALITY ❑ 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 /> 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 /> Water Supply Source ��” Animal Waste Disposal Method <br /> 6, CONSULTATION FEE �fL /A_)& 15996f<L4n)f> %-0tf 1/U5P= <br /> T. ❑ .PLAN CHECKING FEE <br /> 8. 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, nd rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X Title da� i Date k-11 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 A Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE f DATE DATE REMITTED AMOUNT DUE CHECKED <br /> yAMOUNT <br /> FEE <br /> e <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> DTHER �b'3 41Sbd01 31l SAbd <br /> 11 1:30 <br /> - - -- <br /> Received by Dale �pl No. Permit No. Issu2*I/Dete Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 1005 STOCKTON,CA 95201 <br />