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' Applications Will Be P�tied When Submitted Properly Completed. Be S�o Sign The Application. <br /> APPLICATION <br /> r ENV19'NMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR .^� IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS, WATER SAMPLING -- "---- -- <br /> EP AND/OR REAL ESTATE INSPECTIONS Lic. No. ----. - _ <br /> SE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regl6t. NO._.. <br /> 1. AER _ _._ _ __. __ q <br /> Color <br /> Application Date� Business/Name To Appear On Permit --54 <br /> Type Permit/Servic / CKplait,-reJ1JS/L-1lSai It <br /> :iApbcant amQGrCr Addy sa sZ <br /> p <br /> C2 <br /> Business Telephone No /,67),52 `e76�3 Emgency Telephone No. <br /> Property Locaton!Address <br /> i <br /> Property Owner . Address __3 _ <br /> !�. <br /> Operator's Name Ir 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 /> 0ENCREATIONAL HEALTH 11 SWIMMING POOL 13 SPA 11 WADING POOL 11 NATURAL BATHING PLACE <br /> CTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> NEL/Runways /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water�S ply Source _ Animal Waste Disposal Method <br /> 6. L7 CONSULTATION FEE Y'G eXCp. U4'Fi tlYL, u�o rK,olc�M(�e.v i e (a/ <br /> 7. ❑ .PLAN CHECKING FEE <br /> S. 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, 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 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 18 Received By January 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE f REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNTOUE CHECKED <br /> FEE ?U <br /> C / JC c ''E AMOUNT_ <br /> 5 { ' /J ������Q uJ' <br /> LESS <br /> PRORATION <br /> PPLUS <br /> ENALTY ..S WILL E APPLIED TO PAST DUE ACCOUNTS 3 <br /> OTHER IMM SI UNG DATE. <br /> OTHER 1/23/89 <br /> db _ OE <br /> Received by Dale Rece.pl No Permit No Issuance Date Mailed Delivered <br /> — APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON.CA 95201-- <br />