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Application*Will Be PIN.- P Y ased When Submitted Properly r ^Completed. Be St-,,40 Sign The Application. <br /> APPLICATION <br /> ENrSINEER S AND:10H ENVIRONMENTAL HEALTH PERMIT/SERVIC <br /> APPLICANT'S ANO 0A 1\,� <br /> CONTRACTOR ANO/OR FOOD ESTAOLISHMENTS.HOUSING �Illiii ItE INVOLVED GIVE <br /> BROKER ANO:Qfa PUBLIC POOLS,WATER SAMPLINGD \r_ Make -___..IrFNSE AND/OR REAL ESTATE INSPECTIONS <br /> POULTRY RANCHES AND KENNELS 1tN0. <br /> I. .aERATiON MISCELLANEOus sERYIcES 1 Re ist. N <br /> Application Date 4h Ce QI _ tRGNpJ1E sE�v`G�S <br /> Business/Name To Appear On Permit CNV MIS <br /> r Type permit/Service RegUeSted: <br /> {Appli nt N$m 300 ' ---_..._. - <br /> u Address.... ! `�2C�Y> I�/ <br /> acct ---. <br /> l q -a� ._..-----------�- � � <br /> --'----- _. Buslnes fele none Na. . ��=. �._ Emergency Telephone �- <br /> Properly LOCation,Address. �Z�w( w .. MO <br /> - <br /> t Property Owner -� J_r l� <br /> -- <br /> Operator's Name _...._ . C <br /> - <br /> 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 Employeeg __••-__�___ _ <br /> ALL APPLICANTS' Total Employees Including Operators__ <br /> . <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 /> ❑ 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 /> Water S *ply Source At, <br /> 'mal Waste Disposal Method __;,,•^, <br /> 8• CONSULTATION FEE ��L' <br /> T, ❑ PLAN CHECKING FEE _ ...._.._ - <br /> 8, REAL ESTATE <br /> REQUEST: Water Well inspection Sample❑ Title Company . <br /> Sewage System Inspection ❑ Address <br /> __....._..._._..._...---- ....----Tele. No._.. ..._ <br /> Escrow No- ------ <br /> Seller <br /> ._..-.Seller __.._.._._.__._ ......... Seller Address <br /> Telephone No. --_ Seiler 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 /> ordinance$. state laws, and rules and regulations of the San Joaquin Local Health District, <br /> APPLICANTS SIGNATURE [7 <br /> elf <br /> YX <br /> Yf�dl_��__ _MnL\qToate .._ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PtH UNIT [] PER SITF ❑ EACH ❑ January t &Received ey January 31 ❑ July t&Recervad By July 31 <br /> BASF I EXPLANATION BILLING REMITTANCE f REMIT <br /> AMOUNT DUE CHECKED <br /> DATE DATE - REMITTED <br /> AMOUNT <br /> FEE I <br /> LESS <br /> PRORATION I <br /> PLUS - <br /> PENALTY <br /> OTHER <br /> OTHER <br /> R,vr,,Vco by Date �Ascelpt No Permit No. Issuance Date Meged Dativered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 160111,NAZILTON AYE..P,O.boat 7009 STOCKTON.CA 9SMI <br /> T i-',7 r-',I 6 •--) <br />