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Applications WIII Be Pro ed When Submitted Property Completed, Be S*o Sign The Application. <br /> APPLICATION <br /> Yr ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> IF VEHICLE INVOLVED,GIVE <br /> ENG;NEER'S AND/OR FOOD ESTABLISHMENTS.HOUSING Make - <br /> APPLICANT'S AND/OR <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR <br /> PEAL ESTATE INSPECTIONS LiC. NO. <br /> IrENSE AND/OR POULTRY RANCHES AND KENNELS gegi5t. NO. <br /> 3TRATION MISCELLANEOUS SERVICES Color <br /> I. AER <br /> f Application Date 111 Business/Name To Appear On Permi <br /> ,Type Permit/Service Requested:_1_5074 - �- - <br /> i u�( $Yi,Q✓ , ,/�._ u�,Address �r O . �l�J� 0 �'^�� vr.rtM S <br /> a Applicant Name y"�.c�iv A <br /> g Business Telephone No. Erni of n y ele2wfphone o. <br /> ,Property Location/Address —L �1 7 s �i L Otil°'Ayl S7/LL✓i <br /> Property Owner ---, �� dress y <br /> l �12 D/F/1 �/ /, _�L C 7 <br /> L Operator's Name ddress <br /> ce <br /> 1. FOOD ESTABLISHMENTS Total uilding Sq. Footage Restaurant,Maximum Seatir4 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 /> I2. 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 /> 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 DispoLaI Method <br /> 6. )�ONSULTATK)N_FEE I 'I C C t <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, 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 1 6 Received By January 31 ❑ July 1 A Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> }� ! DATE( DATE REMITTED AMOUNT_ <br /> FEE -*i e, l71 of �UD <br /> LESS ' r <br /> PRORATION <br /> PLUS <br /> PENALTY FBF IAl -C <br /> OUNTS"U <br /> OTHER Ui1i� =ROiVi l3iLLIN , DAiE. <br /> OTHER <br /> Received by Date Receipt No. Perms No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sea 200 STOCKTON,CA 95201 <br />