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Applications Will Be Proces d When Submitted Properly Completed. Be Sure Tr Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVIC <br /> ENGINEER'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 ? REAL ESTATE INSPECTIONS Lic. NO. <br /> .IrENSE AND/OR POULTRY RANCHES AND KENNELS Regist. NO. <br /> STRATION MISCELLANEOUS SERVICES g <br /> 1, .BER I x Color <br /> [Application Date/ Business/Na�a/To Appear On ermit <br /> oType Permit/Service��R--eqq``uested: 2 AG�K <br /> a Applicant Name X1� y��, a -\Jc�1L--1�n+? ddress <br /> U5 uslneJss Telephone No. �'Gam+�' Emergency Telephone No. <br /> ap t, Location/Address�( d(� �` ptta \ � -r—�2�1 4 �1g4.+n s�9m�-mac- Y °t�+,�Go �,�c <br /> d Property Owner;��Na14 41K�.4N'�� -- Addresses a�� eQC- <br /> a ` <br /> Operator's Name � Q � A � Address tt c� <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 Y M E N.T <br /> 11HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPARA <br /> ❑ MOBILE HOME PARK/No. of Spaces RECEIVED <br /> 3. WATER DUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER AUG 12 1988 <br /> NO, OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL B,jWWCF IW(fNTAL HEALTH <br /> 5'. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds PEWITISEPMCES <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. JC PLAN CHECKING FEE r - <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 I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATUR X Title Qcc.ti..]- � Date \y� <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 /> BILLING 1ITTANCE $ REMIT <br /> BASE EXPLANATION DATE TE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT_ <br /> FEE Q n K <br /> LESS <br /> PRORATION <br /> PLUS + <br /> PENALTY <br /> OTHER Q <br /> OTHER <br /> jR ived by Date cel pt No. Permit Na Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENV W MENTAL HEALTH PERMIT/SERVICES 1601 E. N AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />