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•Aj . Applications Will Be Proed When Submitted Properly Completed. Be Sura <br /> urr Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL 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 /> BROKER AND/OR REAL ESTATE INSPECTIONS LIC. No. —. <br /> .IrENSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> STRATION MISCELLANEOUS SERVICES <br /> I. .aER Color <br /> (Application Date Business/N a To App=r Pe mit <br /> W Type Permit/Service Request .f�� <br /> `Applicant Name Address �73r [•1La&L n 6 <br /> Bu 'ness T ne Emergency Telephone No. <br /> aProperty I t' /�dd / <br /> Z 60 N• �• a ice• <br /> aProperty OwnerI�^"s'Ivb`�'�i fA A&AA-- — Address <br /> [Operator's Name SJA Address A <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT 11 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 /> 11 FOOD CROP HARVESTING/No.of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators � <br /> ❑ HOTEL/MOTEL/No. of Units trytq <br /> 2. HOUSING ❑ CERTIFICATE OF OCCUPA,cCY OCT j <br /> Fy <br /> ED <br /> ❑ MOBILE HOME PARK/No. of Spaces `t���fy(1^J^ c2 1989 <br /> 3. WATER OUALITY <br /> ❑NO OF PUBLIC SYSTEM <br /> PUBLIC C SERVED ❑ WATER ct❑ SURFACE WATER SUPPLY WATER HAULER(Bacterial) CHEMICAL <br /> CH❑ ( ���r`'�'TIS�RVILTH <br /> �� s <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 Disposal Method <br /> 6. ❑ CONSULTATION FEE <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 i a Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> O <br /> FEE L <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER PPL ED TO PAST UE ACCOU 30 <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,P.O.Bos 2009 STOCKTON,CA 95201 <br />