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Applicaliocs WilliffocessedWhen Submitted Properly Completed. ure To Sign The Application. APPLICATION 0 ENVIRONMENTAL HEALTH PERMIT/SERVICES ENGINEER S AND,OR IF VEHICLE INVOLVED, GIVE APPLICANTS AND OR F000 ESTABLISNMEHTS.HOUSING Make A CONTRACTOR AND�OR , PUBLIC POOLS, WATER SAMPLING - 13HOKEH AND,OR REAL ESTATE INSPECTIONS LIG- No. FAND/OR --.-......-------- -- irNSE AND,OR - POULTRY RANCHES AND KENNELS Reglst. No. 3TRATION 1 MISCELLANEOUS SE'IRVICfS Color aER Application Date ____ _ - �usirless/Name To Appear On Permit _- -____-------- . ----- --- . - ,,,Type Permit!Servlce Requested: _----- -_ — ------_-_ a Applicant Name ---__Hirnec---Construction -_ --- Address .4609.__N_ew_-Ho-ri_ cin,-_S�11c Bakersfield,_.CA_ _93.3.13_. Business Telephone No ..--------.--- - - -. Emergency Telephone No. Property Location/Address --_.._2.701_Wllso_n_Mayr_ Stockton aProperly Owner Address - -LOperator's Name -- ------ ------ - -- Address --- — ]. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity ❑ RESTAURANT ❑ FOOD MARKET RETkI).. ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET ❑ FOOD PROCESSING PLANT ❑ COMMISSARrY ❑ ICE PLANT ❑ BAKERY ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR ❑ VENDING MACHINES/No. of - _ -____.._T 1 ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE ❑ FOOD CROP HARVESTING/No. of Field Employees ---- ------ ALL APPLICANTS: Total Employees Including Operators 2. HOUSING ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY ❑ MOBILE HOME PARK/No. of Spaces — 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY '© WATER HAULER NO. OF PUBLIC SERVED (Connections) 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds _._---- r "ENNEL/Runways /Animal Population No. —. _ No.of Confining Cages Sewage Disposal Method Solid Waste Disposal Method - Water Supply Source Animal Waste Disposal Method 6. ❑ CONSULTATION FEE - 7. ❑ PLAN CHECKING FEE 8, REAL ESTATE REQUEST: Water Well Inspection[] Sample[] Title Company Sewage System Inspection © Address m. __._.__._ _Tele. No. Escrow No. --- ---- -- --- Seller _ _.— Seller Address Telephone No. Seller Agent Name Service Request For Date - --------. - -_-.- --___ _— I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws. APPLICANT'S SIGNATURE X ------.---. - ------ -- Title — Date FOR DEPARTMENT USE ONLY Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &R y July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE K CHECKED DATE DATE REMITTED AMOUNT FEE 9-21- -p ,$52-.50 Inspect-i n LESS PRORATION PLUS G PENALTY---------$. 5-25—__ .2-enalty OTHERT` $5.77 E.en.al t ]_L- 9-9 - 3rd Bi 1 _n $6.3.52 _ OTHER Received ivy Date Recu,pl No Permol No� Issu.-nce Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITiSERVICES 1601 E-HAZELTON AVE..P.O.Box 2009 STOCKTON,CA 952011--