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Applications WIII Be Pr"^essed When Submitted Properly Completed. Be S - To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR FOOD 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 /> 3TRATION MISCELLANEOUS SERVICES g <br /> I. .8ER G f. Color <br /> [Application Date " oG _ Business/Name To Appear On Permit <br /> MType Permit/Service Requested: E` <br /> Applicant Name - I E G' S`{5 S Ad rays -{IO) = "6W EV— 1"N ? C L Izl &�7C) <br /> Business Teleph ne N 52—2.101 14V5 2!0 <br /> ,Property 1 t /Add OIC W �T�YfN IAS <br /> J Property Owner Address <br /> LOperator's Name Address <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 VE <br /> ❑ FOOD CROP HARVESTING/No.of Field Employees / G n <br /> ALL APPLICANTS: Total Employees Including Operators C��0 LOJ` 7- 1 <br /> 7 HOUSING <br /> -Q HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces �l <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 0 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 Disponi fkei <br /> S. FbONSULTATION FEE Sl l 1"C�I 1�-�� <br /> 7. PLAN CHECKING FEE <br /> 8. REAL ESTATE D <br /> REQUEST: Water Well Inspection Sample[] Title Company <br /> Sewage System Inspection ❑ Address <br /> Escrow No. PE <br /> Seller Seller Address I_—rVEill TH <br /> Telephone No. Seller Agent Name [`:�`'""""•"' ' r' <br /> Service Request For Date 1 <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. L� <br /> APPLICANT'S SIGNATURE — Title ���TCti•I rly 0� Date 's <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 REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER !.'1 ST I 07— u17/28 ni, <br /> Y <br /> OTHER <br /> Receive0 by Date Reo. Permit No. Issuancer(e Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIROMMYNTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE.,P.O.00.9009 STOCKTON,CA 95]01 <br />