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Applications Will Be P�ssed When Submitted Properly Completed. Be Su To Sign The Application. APPLICATION ENVIRONMENTAL HEALTH PERMIT/SERV CES ENGINEER'S AND/OR IF VEHICLE INVOLVED,GIVE APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING BROKER AND/OR REAL ESTATE INSPECTIONS LIC. NO. .Ir'F_NSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. STRATION MISCELLANEOUS SERVICES I. . QOIOr BER f Application Date ao Business/Name To Appear On Permit C v, C�l'F clL FType Permit/Service Requested: D Applicant Name ddress g Ijusiness I h Emergen Telephone No. J %Property Location/Ad ,aass a Property Owner. M Address -Operator's Name 577A Address 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR ❑ VENDING MACHINES/No.of ❑ 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 PAYMENT - 3. WATER DUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL RECEIVED ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER NO. OF PUBLIC SERVEDlConnections) JUp 1 G 1988 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA IJ WADING POOL 11 NATURAL BATHIN PLACE � ' 1 S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds ENVIRONMENTAL HEALTH 1 r :ENNEL/Runways /Animal Population No. No.of Confining Cages __ Sewage Disposal Method • 11"•„'/' Solid Waste Disposal Method Wat r Supply Source Animal Waste Disposal Method 6ONSULTATION FEE 7. [U PLAN CHECKING FEE 8. REAL ESTATE REQUEST: Water Well Inspection[] Sample[:] Title Company Sewage System Inspection ❑ Address 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, and rules and regulations of the San Joaquin Local Health District. .//(, APPLICANT'S SIGNATURE X Title AkAMAZ Date " Hi FOR DEPARTMENT USE ONLY Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT_ FEE © � I6 T�{� /D LESS PRORATION - PLUS PENALTY OTHER OTHER Received by Difte Receipt No. Pe,m,t No Issu nce ate Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box Moe STOCKTON,CA 95201