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RECEIVED DEC 0 5 1989 <br /> Applications Will Be PrG`ssed When Submitted Properly Completed. Be S� o Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR I DOD ESTABLISHMENTS,HOUSING Make <br /> ND/OR PUBLIC POOLS.WATER SAMPLING <br /> CONTRACTOR A gEAI ESTATE INSPECTIONS LIC. No. <br /> BROKER AND/OR <br /> .IrENSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TRATION ^' ^'' f MISCELLANEOUS SERVICES Color <br /> I, .BER _ 7X �-'ANL4D <br /> [Application Date Business/Name To Appear On Permit - - <br /> UlType Permit/Service Requested: <br /> i Applicant Name \AALTrA F_OGINy EEIZ1N� Address P�3�1 \S KG t-Anr <br /> 0 \.O eg. SOJ`('OP!\P_1�-�b 95�9 1 Business T9,lephone No. Emergency Telephone No. <br /> `Property Location/Address L"4 O W Al..Trp L7 _ <br /> _1PropertyOwner -(�`�d C nn-lai a e�(�[72� Address SO,I"\�- i2CS SE <br /> � e <br /> 10perator'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 <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 TNNEL/Runways /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Wate;r Sy�ly Source _ Animal Waste Disposal Method <br /> 6. 6d" CONSULTATION FEE 3- - nur 5 nJe("�1MG I1S_L\ ec�tOn P+ 501 5� �c[' 't%okkif _ <br /> 7. ❑ PLAN CHECKING FEE �'�—� t v A 1 1 C y> <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Semple❑ Title Company <br /> Sewage System Inspection ❑ Address PAYMENPr <br /> Escrow No. RECEIVED <br /> Seller Seller Address AN <br /> Telephone No. A N (y'IISeller Agent Name <br /> Service Request For Date <br /> 'v-/ �� `-I <br /> �'; Tv <br /> FU <br /> I hereby certify that I have prepared this application and that the work will be d IRaTldb Wittt'Spn Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health Distric. IAL r!c <br /> APPLICANT'S SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 &Receiv By July 31 <br /> R IT <br /> BABE E <br /> XPLANATIONMITTANCE $ AMO T DUE CHEC ED <br /> DATE REMITTED AMOU T <br /> I S <br /> FEE SD <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON.CA 95201---- <br />