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ENGINEER'S AND/OR <br />APPLICANT'S AND/OR <br />CONTRACTOR AND/OR <br />BROKER AND/OR <br />.IrFNSE AND/OR <br />3TRATION <br />I. 8ER <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />FOOD ESTABLISHMENTS, HOUSING <br />PUBLIC POOLS, WATER SAMPLING <br />REAL ESTATE INSPECTIONS <br />POULTRY RANCHES AND KENNELS <br />MISCELLANEOUS SERVICES <br />IF VEHICLE INVOLVED, GIVE <br />Make _ <br />Lic. No.- <br />Regist No. <br />— -- COIOr . -- — — -- — <br />f Application Date ZZ M __ .-_ Business/Name To Appear On Permit �_ jl�/) L% t /by6 WlP✓ 4 <br />wType Permit/Service Requested: <br />Applicant Name GIm ddress ��ji� �r%Z _ M,0-Cec G 9S -3 1/o <br />a�+�� — Busin ss Telep one No. 3� -10 q1 Emergency Telephone No.�7� "?-S3 y,$ <br />Property Location/Address —lsi._ 1 er, �$ 33 6 <br /><Property Owner ra M Vb [-' ____— Address Pb goX % _ , <br />Operator'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 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 - ._ - - t <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 />S. 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. ACONSULTATION FEE <br />7. ❑ PLAN CHECKING FEE <br />8. REAL ESTATE <br />REQUEST Water Well Inspection[] 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, anc/r�,u,les and regulations of the San Joaquin Local Health District. <br />APPLICANT'S SIGNATURE X J)JV _ ----- —Title rate 2IW <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITF ❑ FAr.H ❑ Inm, 1 A A. 1.--, '11 ❑ .... , ■ o o.. <br />Received by Date <br />APPLICANT—RETURN ALL COPIES TO: <br />CK- t4 \\S <br />Receipt No. Permit No. <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />Issuance Date Mailed Delivered <br />1601 E. HAZELTON AVE.. P.O. Bax 2009 STOCKTON, CA <br />BASE <br />— <br />EXPLANATION <br />BILLING <br />REMITTANCE <br />$ <br />AMOUNT DUE <br />REMIT <br />CHECKED <br />_ <br />DATE <br />— -- -- <br />DATE <br />REMITTED <br />AMOUNT <br />-- <br />— <br />FEE— <br />— <br />--- --- <br />LESS <br />PRORATION <br />-------- <br />PLUS <br />- <br />— <br />- - <br />PENALTY <br />OTHER <br />OTHER <br />Received by Date <br />APPLICANT—RETURN ALL COPIES TO: <br />CK- t4 \\S <br />Receipt No. Permit No. <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />Issuance Date Mailed Delivered <br />1601 E. HAZELTON AVE.. P.O. Bax 2009 STOCKTON, CA <br />