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Applications will ee P�when Submitted properly Completed. be �yn I hr Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> EN;GINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OP FOOD ESTABLISHMENTS.MOUSING Make <br /> CONTRACTOR AND/CIR PUBLIC POOLS.WATER SAMPLING <br /> BROKER AND/OR HEAL ESTATE INSPECTIONS Lic. No. <br /> LICENSE AND/OR POULTRY RANCHES AND KENNELS <br /> RE&MT"TION n MISCELLANEOUS SERVICES Regist. No. <br /> hLIM EA A419 SLK Color <br /> f Application DateD p _ Business/Name To Appear On Permit .t ��M P Qt)� <br /> *Type Permit/Service Requested: F-Le" <br /> Applicant Name� �►d //o�a''121�1�C 9 - <br /> ��� ��21 �6.1�T+ �✓a �j8O32 <br /> U <br /> C. tD� `sjness Telephone No.ZPI I_��$_ Emergency Telephone No. .$Il1+iG <br /> Property Location/Address �� 1. I f. -- .�.isinS`jbC.KTO11 <br /> Property Owner �+�, ,�! (.£l1M_ � ___-__ Address 55 5 • TL+lAP— S�'1—LrA►, <br /> L Operator's Name 4 Y4t _SPIE _ _ _ Address — -- ' <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT tg FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIOUOR 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 _._.3T- --_- <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 /> Ip 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 /> a VENNEL/Runways _— /Animal Population No. _ No. of Confining Cages <br /> G <br /> Sewage Disposal Method `1m1/ OF 5,�mi4 __— <br /> Solid Waste Disposal Method �At <br /> Water Supply Source Animal Waste Disposal Method <br /> 6. ❑ CONSULTATION FEE <br /> 7. 19 PLAN CHECKING FEE £ <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection C3 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, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X . �_ _ _ Title Gpo11ZID11�lA�i� Date..4-13f_g - ---.-- <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 6 Received By July 31 <br /> - -- ----' — -�-- — REMIT <br /> BASE EXPLANATION BILLING REMITTANCE T AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS -- -- <br /> PENALTY <br /> ONIER <br /> OTHER <br /> Received by Oale Rec.. No Permit No Issua nr.e Ma.led Delivered <br /> APPLICANT—RETURN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E HAZELT00 AVE_P.O Bo, 2009 STOCKTON.CA 95201 <br />