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r J nr G�i� APPLICATION <br /> £NVIIAONMBNTAL HEALIH PEPiAtl-ftgF_HvIC1!S <br /> Ft1GiNEEN 5 ANO um IF VEHICLE INVOLVED GIVE <br /> APPILICAkTS ANb UR 1`0411 ISTA8L13dtAINTS NOUSitCZ A11+\f <br /> L.JN I HA 11411 At<IU L+14 PUROC POW &91141114]BILLING ' <br /> BROKEN ANEPOR SEAL I&TATi WSPtcTIONS Lic No <br /> VSE AND OR POULTRY NANCNEtI AND KINNELS RC ill No <br /> TRATION M14CELLANFOUS$E11VIC9S g —�� <br /> .1ER Co or <br /> Application Date _ 1�- Business/Nan-ie To Appear On Permit <br /> „Type Permit/Service <br /> t,cRequested <br /> / �___ _�, `' ,{ <br /> aApPlicantName wG+lelf�rC7�J�cf�ie/ L�?—__ __ Address �12 0 �__ 4r45�IIQ� <br /> Business Telephone No Emergency Telephone No — _ - <br /> -Property Location/Ad�drress <br /> Property Owner - nv/ -__ �_ � - _ Address - <br /> Operators Name w__ _ _- -_- __-___- __-_-__ Address _- <br /> T FOOD ESTABLISHMENTS Total Building Sq Footage Restaurant Maximum Sealing 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 Feld Employees <br /> ALL APPLICANTS Total Employees Including Operators <br /> 2 HOUSING <br /> ❑ HOTEL/MOTEL/No o1 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 /> VECTOR CONTROL ❑ POULTRY FARM/Maximum No of Birds - _ { <br /> �ENNEL/Runways /Animal Population No - No o1 Confining Cages <br /> kewage Disposal Method <br /> Solid Waste Disposal Method - <br /> Water Supply Source � Animal Waste Disposal Method <br /> 6 CONSULTATION 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 and rules and regulations of the San Joaquin Locat Health Distnct <br /> APPLICANTS SIGNATURE X — Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 b Received by January 31 ❑ July 1 6 Rpcewed By July 31 <br /> 1 BILLING REMITTANCE ' S REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT OUr3 CHECKED <br /> AMOUNT <br /> FEE J. Q MZ5 <br /> LESS P� It 1 Tl,-(%j"r,+ ' ��- / r1 I`h TO EA _,-:, 1r �' fid©. <br /> M PRORATION <br /> PLUS <br /> PENALTY <br /> !i <br /> 4� pis <br /> OTHER � <br /> OTHER 7/3/ <br /> 3/20 aR ___ _✓ _— <br /> VReceived 4y Date Rece,pl No WPermA No Iswance Dale Meded Delivered <br /> L APPLICANT—RETURN ALL COPIES TO ENVIRONMENTAL HEALTH PERMITrSERVICES 1601 E HAXELTON AVE P 0 Bax 200 STOCKTON CA 96201 <br />