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Applications Will Be Pressed When Submitted Properly Completed. Be S To Sign The Application. <br /> . APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVI ES <br /> E'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> ENGIN <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING Make - - <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING L -- <br /> REALEST ATE INSPECTIONS IC. No. <br /> BROKER AND/OR <br /> j r.ENSE AND/OR POULTRY RANCHES AND KENNELS Regist. N0. - <br /> 3TRATION MISCELLANEOUS SERVICER Color <br /> I, .8ER ,I[' /'�1 q <br /> (Application Dale V Business/Name To Appear On Permit N S.SI(AJa2ca,8_4 - <br /> IFType.Permit/Service Requested: A��' ` <br /> aApplicant Name AM ddres 0• <br /> us! <br /> irygss Telap 0 a �e)7 V "j 16 1 Emergency Telephone No. <br /> a (J p04 <br /> 0.Property Location/Address <br /> Property Owner Address <br /> a Address <br /> Operator's Name <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 /> 11HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER OUALITY ❑ 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 /> ( :ENNEL/Runways /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Animal Waste Disposal Method <br /> Water Supply Source <br /> 6. ❑ CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE <br /> B. REAL ESTATE AUG 91988 <br /> REQUEST: Water Well Inspection Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <br /> IRONMENTAL HEALTH <br /> Escrow No. PERMITISERVICES <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 a that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a e and re at`ns of an J quln Local Health District, <br /> APPLICANT'S SIGNATURE X — Tit Date <br /> F R DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 &Received BAyl July 31 <br /> RE <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT_ <br /> FEE (0LESS <br /> 0� <br /> PRORATION J • ��� -/ <br /> PLUS ✓` �Q <br /> PENALTY <br /> OTHER 14 <br /> OTHERoaS <br /> vetl by Date t No. Permit No. Issue ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2ELTON AVE.,P.O.BOM 200 STOCNTON,CA 95201 <br />