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Applications Will Be Firocfeed When Submitted LICATION Completed. Be Sur Sign The Application.\ '^ <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES IF VEHICLE IE INVOLVEEDD,GIVE <br /> ENGINEER'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make <br /> APPLICANW S AND/OR PUBLIC POOLS,WATER SAMPLING Lic. NO. <br /> CONTRACTOR AND/OR REAL ESTATE INSPECTIONS <br /> BROKER AND/OR POULTRY RANCHES AND KENNELS Regal. No. <br /> ICENSE AND/OR MISCELLANEOUS SERVICES <br /> 3TRATION COIOf <br /> I. .BER <br /> [Application Date 8� Busin s/Name To Appear On Permit <br /> �ss'E Sr�ts Q�w <br /> FType Perr iVService Re ested: <br /> a Applicant Name j �e ._A'dtdrress SV <br /> O Business Telephone NaP�7/ Emergency Telephone No. <br /> J <br /> n <br /> 'a Property Location/Address Address <br /> (Property Owner S <br /> a A Address <br /> (Operator's Name Restaurant, Maximum Seating Capacity <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage ❑ MEAT MARKET <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL E3 FOOD MARKET WHOLESALE <br /> ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> 11 FOOD PROCESSING PLANT ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ ROADSIDE FOOD STAND C1 LIQUOR STORE ❑ FOOD VENDOR <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER 13 FOOD DEMONSTRATION <br /> 11MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> 11 VENDING MACHINES/No. Of <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING y Y <br /> ❑ CERTIFICATE R E Si ' p <br /> ❑ HOTEL/MOTEL/No. of Units Ci CC <br /> ❑ MOBILE HOME PARK/No. of Spaces ❑ CHEMICAL <br /> 3. WATER DUALITY ❑ WATER SAMPLE (Bacterial) t, UV 4 1988 <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER 1,V Y <br /> NO. OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL 11 SPA 11 WADING POOL c3 If►iW1 QW II ETA Sg� .TH <br /> 5. VECTOR CONTROL 13 POULTRY FARM/Maximum No. of Birds <br /> IC <br /> r :ENNEL/Runways /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Animal Waste Disposal Method <br /> Water Supply Source — - <br /> 6. ❑ CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample 1:3 Title Company <br /> Tele. No. <br /> Sewage System Inspection <br /> ElAddress <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 re San Joaquin Local Health <br /> +,District. <br /> 5E7 <br /> APPLICANT'S SIGNATURE X Title Date e i 41 cpd? <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 6 Received By January 31 ❑ July 1 SfleceiveddEBAyl July 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE 55. <br /> LESS 3S — <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date <br /> Receipt No. P t NO. las en a D le M led D I d <br /> TH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA 952 <br /> 01— <br /> — APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEAL <br />