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Applications Will Be P�Bed When Submitted Properly Completed. Be o Sign The Application. <br /> APPLICATION <br /> ENGINEER'S AND;OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> APPLICANTS AND/OR FOOD ESTABLISHMENTS,HOUSING IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> 3TR <br /> IrE ANOPOULTRY RANCHES AND KENNELS <br /> STRATTONN MISCELLANEOUS SERVICES RegiSt. No. <br /> I, .dER Color <br /> (Application Date �— Busy'�e s/Name 1%Appear On Permit <br /> til Type Permit/Service equested:Date_,,, <br /> K F'�CL In Y/ Ifv�= ---- <br /> z <br /> u Applicant N me 4L Address n6., <br /> u u ines Teleph No. Q' — — '1Tr <br /> Emergency Telepo, <br /> aProperty Location/Ad ass. O <br /> a one Property Owner Address gs— <br /> LOperator'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 /> 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 isposal Method <br /> 6. �G`ONSULTATION FEE f/Dho %�pP �„�Q,ti ��,��p_rJ GL�S77 -- <br /> 7. ❑ PLAN CHECKING FEE --- _ <br /> 8. REAL ESTATE -- <br /> REQUEST: Water Well Inspection[] Sample❑ Title Company <br /> Sewage System Inspection ❑ Address <br /> Escrow No. . P --- <br /> Seller __ Seller Address REC'RECEIVED <br /> Telephone No. Seller Agent Name <br /> Service Request For Date —W� <br /> I hereby certify that I have prepared this application and that the work will be done i c p[d�r�MMtP�a County <br /> ordinances, state laws,and rules and regulations of the San Joaquin Local He.—.—., '✓!Y;"Y!` <br /> PERMITPE�,TISERVI ESS <br /> APPLICANT'S SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee 19 Due: ❑ ANNUALLY ❑ PER UNIT Q PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNTDUE CHECKED <br /> AMOUNT <br /> FEE �( _ <br /> LESS <br /> PRORATION <br /> Plus <br /> PENALTY DAYS RCM t CC UNTS 30 <br /> OTHER <br /> OTHER <br /> 'l S <br /> Recertl by Date Receipt No. Permit No. Issuance Data Mailed Delivered <br /> — APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />