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Applications Will ace 9 When Submitted Properly Completed. ire Sign The Application-PU <br /> r APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES IF VEHICLE INVOLVED, GIVE <br /> EN1Z19'AND/OR - FOOD ESTABLISHMENTS,HOUSING Make <br /> APPLICANT'S AND/OR D �' PUBLIC POOLS.WATER SAMPLING Lic. No. <br /> CONTRACTOR AND/OR �r^\�(11� HEAL ESTATE INSPECTIONS Regist. No. <br /> BROKER AND/OR 1` I I 1�" POULTRY RANCHES AND KENNELS <br /> IrE AND/OR \\\\\\\\JVJJJJ/// u UUU MISCELLANEOUS SERVICES COIDf <br /> STR <br /> STRATTON V <br /> I. .dER <br /> f Application Date Business/Name To Appear On Permit — <br /> I.Type Permit/Service Requested: Address 1100 -N Wilson W <br /> i Applicant Name CO R <br /> sinlNo Emergency Telephone No. <br /> ° Glib Usones�J�ayep �kn 95205-- <br /> 6 <br /> 'a Property Location/Address Address <br /> I <br /> Property Owner Address <br /> �LOperator's Name Restaurant, Maximum Seating Capacity <br /> 1. FOOD ESTABLISHMENTS Total Building Sq❑ FO <br /> FootageOD MARKET WHOLESALE ❑ MEAT MARKET <br /> 11 RESTAURANT ❑ FOOD MARKET RETAIL ❑ ICE PLANT ❑ BAKERY <br /> C1 FOOD PROCESSING PLANT ❑ COMMISSARY 13ITINERANT RESTAURANT <br /> 13F LIQUOR STORE 11 BAR ❑ FOOD VENDOR <br /> ❑ ROADSIDE FOOD STAND ❑ FOOD SALVAGER 11 FOOD DEMONSTRATION <br /> ❑ CONFECTIONARY STORE ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ VENDING MACHINES/No. of <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ HOTEL/MOTEL/No. of Units <br /> ❑ MOBILE HOME PARK/No.of Spaces ❑ CHEMICAL <br /> 3. WATER QUALITY 11 WATER SAMPLE (Bacterial) 11 WATER HAULER <br /> 13 PUBLICWATER SYSTEM ❑ SURFACE WATER SUPPLY <br /> NO. OF PUBLIC SERVED (Connections) ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds No.of Confining Cages <br /> r :ENNEL/Runways /Animal Population No. .__. <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method Animal Waste Disposal Method <br /> Water Supply Source — <br /> g, ❑ CONSULTATION FEE <br /> 7, ❑ PLAN CHECKING FEE <br /> a. REAL ESTATE <br /> ❑ Title Company <br /> REOUEST�. Water Well InspectionTele. No.❑ Sample Address <br /> Sewage System Inspection <br /> Escrow No. <br /> Seller Seller Address <br /> Telephone No. Seller Agent Name <br /> Service Request For Date <br /> . cation and that the work will al done in accordance with Sen Joaquin County <br /> I hereby certify that I haveprepared this appli <br /> ordinances, state laws, and rules and regulations of the Sen Joaquin Local Health District. <br /> ' Title Date <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> FCB IS Due: ❑ ANNUALLY PER UNIT ❑ PER SITE EACH ❑ January 1 8 Received By January 31 <br /> eceiv d By REMIT 71 <br /> BILLING REMITTANCE $ MOUNT DUE NECKED <br /> BASE EXPLANATION DATE DATE REMITTED MOUNT_ <br /> FEE In <br /> 5190 $ 0 <br /> LESS <br /> PRORATION <br /> PLUS PENAL IES WILL R! A P! 71",T,',P <br /> PENALTY <br /> Lurgi = Dtirz. <br /> OTHER <br /> OTHER <br /> QA, <br /> mei <br /> Delivered <br /> Received by <br /> Date -'Receipt No. Permu No. S3,..ante Dele Mailetl <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES —1601 E.HAZELTON AVE.,P.O.eon 1009 aTOCKTON,CA 96201—' <br />