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Applications WIII Beed When Submitted Properly Completed. B949 <br /> o Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGi,NEER'S AND/OR - IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR F000 ESTABLISHMENTS.HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS, WATER SAMPLING <br /> BROKER AND/OR FEB 1 I 1989 REAL ESTATE INSPECTIONS LIC. No. <br /> .I(`.ENSE AND/OR POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES Regist.ISt. No.3TRATIONAM Color11�121314 <br /> f Application Date_G '�`7 Business/Name To Appear On Permit <br /> "Type Permit/Servic1e'R.eequested: L� <br /> iAp IcantName P�-� �- n�LTBtJ Address '�3'. '??TZ 111) (AITF. <br /> R[ RAwtauTv Gh 4582' ' { <br /> i B11u��iness Telephone No. Emergency Telephone No. <br /> `Property Location/Address 2.10+0 VUP�i I�'LIJ�rTnN <br /> ,Property Owner CALIFKLM C10PcIL? Address <br /> -70perator'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 PAYMENT <br /> 2. HOUSING RECEIVED <br /> ElHOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces E,'Ap 19893. WATER QUALITY 11 WATER SAMPLE (Bacterial) 11 CHEMICAL MAR <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER 13111111EALTH <br /> H <br /> NTAL <br /> NO. OF PUBLIC SERVED (Connections) ENVIRONMENTAL <br /> H S <br /> 4. RECREATIONAL HEALTH SWIMMING POOL SPA WADING POOL NATURAL BATH <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> r :ENNEVRunways /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method - �-- _ <br /> Solid Waste Disposal Method <br /> Water Supply Source _ Anifpal WasteDisposalMethod <br /> 6. �CONSULTATON FEE �IA LTiFi�krO f LV Lt�.� <br /> 7. 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 t pplicaI. and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws and ules d gul 'ons the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE 4 11A, Tit l Date z <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNI ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July I fl Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT_ <br /> FEE IL ,rn �4.25 ff6 (35.00) <br /> LESS PENALTIES WILL BEA PLIED TO PAI T DUE ACCOi INTS 30 <br /> PRORATION <br /> PLUS DATE. <br /> PENALTY <br /> OTHEflA� l to 2 116/89 <br /> OTHER /'�• Z �'"' <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1901 E.HAZELTON AVE.,P.O.Boa 2889 STOCKTON,CA 95201 <br />