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Applications Will Be Process I When Submitted Properly Completed. Be Sure T,Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES IF VEHICLE INVOLVED,GIVE <br /> ENGINEER'S AND/OR` FOOD ESTABLISHMENTS.HOUSING Make <br /> APPLICANT'S AND/OR PUBLIC POOLS.WATER SAMPLING LIC. NO. <br /> CONTRACTOR AND/OR REAL ESTATE INSPECTIONS RegiSt. NO. <br /> BROKER AND/OR POULTRY RANCHES AND KENNELS <br /> 1CFNSE AND/OR MISCELLANEOUS SERVICES Color <br /> 3TRATION <br /> I. .BER - <br /> ( <br /> 31 Business/Name To Appear On Permit <br /> Application Date <br /> ,Type Permit/Servic Requested:— Address Q'aQ R SL1JEi'�s <br /> L <br /> N <br /> i Applicant Name Emergency Telephone No. <br /> o Z Busine�s Telephone No. <br /> 2to3 B ( I JI IAj BSD <br /> <Property Location/Address _ Address <br /> Property Owner �. Isr Address <br /> -LEpereleds Name <br /> Total Building Sq. Footage Restaurant,Maximum Seating Capacity <br /> 1. FOOD ESTABLISHMENTS ❑ OD MARKET WHOLESALE ❑ MEAT MARKETFO <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ ICE PLANT ❑ BAKERY <br /> 11 FOOD PROCESSING PLANT [I COMMISSARY ❑ ITINERANT RESTAURANT <br /> [3 LIQUOR STORE ❑ BAR <br /> C1 ROADSIDE FOOD STAND SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> El CONFECTIONARY FOOD SALCONFECTIONARY STORE ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEA*wf M ENT <br /> ❑ VENDING MACHINES/No. Of -- - RECEIVED <br /> ❑ FOOD CROP HARVESTING/No.of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators — SEF 2 n J19O88 <br /> 2. HOUSING ❑ CERTIFICATE OF OCCUPANCY LF J <br /> ❑ HOTEL/MOTEL/No. of Units ENVIRONMENTAL H <br /> 13 MOBILE HOME PARK/No.of Spaces El CHEMICAL PERMIT�SERVICESALTH <br /> 3. WATER QUALITY WATER SAMPLE (Bacterial)SURFACE WATER SUPPLY ❑ WATER HAULER <br /> 11 PUBLIC WATER SYSTEM <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 No. of Confining Cages <br /> r :ENNEL/Runways /Animal Population No. <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> I Source Animal Waste Disposal Method 6 <br /> Water Supply - r �l0 � ZC.7�1 <br /> 6. CONSULTATION 1::EE S <br /> 7. PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample❑ Title Company Tele. No. <br /> Sewage System Inspection ❑ Address <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 Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 A Receiv REMIT By <br /> 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ 6AMOUNTDUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 10.00 REVI RELESS <br /> PRORATIONPLUS 00 <br /> PENALTY <br /> OTHER PENAL II WILL BE PPLIED TO P STD ACC IN <br /> OTHER <br /> Ism <br /> Received by Date Receipt No. Pern No. Issuance Date M led Del tl <br /> m <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Boa 2005 STOCKTON,CA 95201 <br />