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Applications Will Be Pr sed When Submitted Properly Completed. Be STo Sign The Application. <br /> APPLICATION <br /> 4 ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/CR FOOD ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS LIC. No. <br /> IrFNSE ANI POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TRATION MISCELLANEOUS SERVICES <br /> I. i3ER CColor <br /> Application Date �� j� Bu}�iness/Name To Appear On Permit/ <br /> Type Permit/Servic Requested: �illl -- <br /> U Applicant NameCC71'11� 0-Address ll. �� ,�,✓ 1�f1 g�-2'�� <br /> elephone No. l Tf0= Emergency Telephone No. <br /> r <br /> a Property Location/Address � �,,,Business,Property Owner �3Z1 - Address <br /> LOperator'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 v�'b <br /> ❑ HOTEL/MOTEL/No. of Units __ ❑ CERTIFICATE OF 0CCU3 f <br /> ❑ MOBILE HOME PARK/No. of Spaces �•�v/YY 18{ <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 /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds _.. <br /> r :ENNEL/Runways T /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method --- <br /> Water Supply Source AnimalW,aa I Disposal Method <br /> 6. !� CONSULTATION FEE �G 11 -�'vs f `� <br /> T. ❑ PLAN CHECKING FEE d <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection[] Sample[3 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 an regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X - �+ Title GENERAL MANAGER Date 11/29/88 <br /> FOR DEPARTMENT USE ONLY <br /> Fee I5 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE Dr S 7(!i <br /> LESS <br /> PRORATION iPn1 CI-1 T(` DUE ACCOUN'FS 3Q <br /> PLUS DAF- 7MI <br /> nB�LLUNG L/%%TE, <br /> PENALTY <br /> OTHER <br /> OTHER <br /> AdakReceived by Date .ipt Na, Permil No. Iss Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENV MENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />