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Applications WIII Se Prod When Submitted Properly Completed. Be SO Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> k!NGINEEfITS AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.EHTS,MOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING <br /> IAHOKER AND/OR E REAL ESTATE INSPECTIONS Lic. NO. -- <br /> jr.FNSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TRATION MISCELLANEOUS SERVICES <br /> I. .BER QOIOr <br /> Application Datea-;l SU 14f � Business/Name To Appear On Permit dINOFR L 5 P`OC'X Tnr.! / � fe F11/'f" (..� <br /> Type Permit/Servi Re uested: <br /> p{Sryc1_AT/o,-/ <br /> =A plican1Name�L /A/FIELOf 11 igA�dLd ass 9 9S8uSin/fss MyeX AR sa/M C , <br /> SgG_AHf, Business Telephgrje No.�1?s5 C K 70 Emergency Telephone No. <br /> Property Location/A es D !/L �- <br /> Property Owner. I OF S ejk Y-V Address <br /> 10perator's Name 6<A10C,4-1, Address,2/75- Cflc�FaR�✓J/hBtro Sv/TE L.f" <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Seating CapacltyW <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET 9�/�9� <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 .2 <br /> 2. HOUSING �v <br /> 11HOTEL/MOTEL/No. of Units 11 CERTIFICATE OF OCCUP i`J�O <br /> ❑ MOBILE HOME PARK/No. of Spaces �fYG �Jj$ <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER ,v\` ���P J C.F•5 <br /> NO. OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING��"��SQ•� <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds Q�Q' <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. XCONSULTATION FEE I°c.../.t r_., �e1Vl1U,1JHI:...M1 x3CGlr Str't•.. T LJO¢/L PC A..lS /Fx(v Je��'a/2y'� <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection E3 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 rul s and eguI I.I the San Joaquin Local Health District. _ ^1 <br /> APPLICANT'S SIGNATURE X r Title `^"trDate <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 6 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER `\ <br /> Received by Date apt No. Permit NO. Ifia ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON.C <br />