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+ Applications Will Be Prod When Submitted Properly Completed. Be Sur Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> EVG!NEEIR--AND/OR IF VEHICLE INVOLVED, GIVE <br /> * AP'PLICANT`SAND/OR FOOD ESTABLISHMENTS,HOUSING Make _ <br /> CO'NfRA&CIR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROkER AND/OR REAL ESTATE INSPECTIONS LiG. Na. — <br /> IrENSE AND/OR POULTRY RANCHES AND KENNELS Regist. NO. <br /> 3TRATION MISCELLANEOUS SERVICES <br /> Color <br /> 1, .BIER - (" <br /> f Application Date � Business/Name To Appear On Permit E2- `+' S �w,f 6ij AAg1 <br /> ,,Type Permit/Service Requested: d <br /> Q Applicant Name S 'r Address <br /> gts� 22Y2 ��tr[�rc� Ca �]S3 <br /> oI3usi ss T I phone No. 20 Emergency Telephone N06°1) "7-S3yS <br /> Property Location/Address �'�QS M9 rk r'G -SC� 5, L <br /> a Property Owner i t � F f ©fid Address _ 1 yD S my" ST 4sc 6 <br /> Operator's Name �A Address SSC <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 /> 5. 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 Disposal Method - <br /> 6. CONSULTATION FEE '21 - - <br /> 7. ❑ PLAN CHECKING FEE <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ Sample El 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 SIGNATURE X Jk Title ' D n / Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> �r DATE DATE RREEyM-IITTEED{x�� AMOUNT <br /> FEE ,�I(J -+"-' r <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �gv <br /> Date pt No. Permit No. Is DateMailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA 95201 <br />