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KLtrt.ly <br /> Liur-I, u a I=) <br /> Applications Will Be P sed When Submitted Properly Completed. Be S o Sign The Application. <br /> 1 ' APPLICATIONpA�,MENT <br /> ENVIRONMENTAL HEALTH PERMIT/SEF*I" f9E I V g D <br /> ENGINEER 5 AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING '�)) M{ake <br /> CONTRACTOR BROKER AND/OR AND/OR PUBLREALIC POOLS,WATER ESTATE INSPECTIONS SAMPLING DEI <br /> 4 »dL C. NO. — _— <br /> irENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> i. AER __- _ INVIRONMENTAL 6&�( H <br /> I SERV <br /> f Application Date_— _ _— — Busi ss/Name To Appear On Permit <br /> mType Permit/Service equested: <br /> aPP � l- lP/� �7� �l—SJfIJE' i <br /> Z A licant Name �— Adtlress /2 !ffiiff�! 1%d�� / iJ'6 <br /> <� pi�4agd� B I/'ess Tel phone91zy;�a� Emergency Telephone No. <br /> a roperty Location/Ad ress SfOa N� C�i'L.w � �,�� <br /> d ProperT�T'C Pn IFf—'T�s Address ��� y .Jdd_t�) �- �KY� <br /> LOperator's Name n 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 <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 /> 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 Dis osal Method <br /> 6. CONSULTATION FEE 4ek- 1Z - —��T <br /> 7. ❑ .PLAN CHECKING FEE <br /> S. REAL ESTATE <br /> REQUEST: Water Well Inspection[] SampleO 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 regular sof the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE XAAR441�1Title � LFe Date <br /> dy/ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION It DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS BE APPLIED TO PAST UE <br /> PRORATION <br /> -ACCO-UM S 30 <br /> PLUS I J-10 1ttING <br /> IL` <br /> PENALTY <br /> OTHER C3 ''+�� <br /> OTHER .�� . 12/7/88 •J{/..� U SZ.5-0 <br /> Re d by Date Receipt No GI No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />