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• - Applications Will Be*messed When Submitted Properly Completed, Boa To 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 /> . �ENSE AND/OR POULTRY RANCHES AND KENNELS <br /> STRATION MISCELLANEOUS SERVICES Regist. No <br /> .8ER Color <br /> Application Date p z CiZ Business/Name To Appear On Permit <br /> in Type Permit/Service Req ested: _ <br /> =A licant ame Q4/rr �j 0 <br /> PP��,��//NN� ,,,,�� 4L.,.. -�----� ��__.__ Address -�—_-- <br /> a [_S_�1* Business Telephone No._. 27 Emergency Telephone No. <br /> %Property Location/Address 43'7�_ � '-0uE ,e-- i��T�nl <br /> Property Owner 0 51 T ti4-- -3-* - AddressAi 4f�lt�r <br /> Operator's Name �G����'N�`�" -<`"' Address D• ,E�D)(Z�Q� / G 45 <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' c� <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees �A4 L <br /> ALL APPLICANTS: Total Employees Including Operators 193F <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. Of Spates <br /> a. 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 /> S. 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 /> 8. REAL ESTATE . <br /> REQUEST: Water Well Inspection 13 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 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws. <br /> APPLICANT'S SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 A Received By July 31 <br /> IT <br /> BASE EXPLANATION BILLING REMITTANCE 5 AMOUNTDLIE E KED <br /> DATE DATE REMITTED - () AMOUNT_ <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER P. <br /> OTHER ' <br /> it <br /> Received by Date ceipl No Permit No tae Dab Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 445 N. San Joaquin St. P.O.Box 4009 STOCKTON,CA 95401— <br />