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Applications Will Be Pr, Issed When Submitted Properly Completed. Be Si' - To Sign The Application. <br /> .n. APPLICATION 410t- <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make _..- <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING —' <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. -- _ <br /> IrFNSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> I. .BER .-_ -. - Color <br /> -Application Date _ 7-amu— Business/Name To Appear On Permit .._ G.H.H. Engineering <br /> oType Permit/Service Requested: _lbi13{-OY''�T� <br /> `Applicant Name _G rp[_-I'� TT' -� __ ___�__ _- _ _ Address ..$_Q8Cz 0 d AL?ourn Road Sl3?mac: F, Citrus <br /> aHeed c�h . 1,SA-95610- _ _ Business Telephone No. _ 01 �^ -7E -_ Emergency Telephone No.(S,3-5) 723-762..s <br /> a Property Location/Address <br /> dPropertyOwner- � e At.�;aL�r_ -___ Address �•G•- Oi� 1GG7, �tOC?{tCn, CA. 49 <br /> C - - -- - <br /> LOperator's Name -S"-Ie__ - _ _._ -_.. Address Sadie <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 ❑ JAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ . RANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ QVENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑FOOD CROP HARVESTING/No. of Field EmployeesALL APPLICANTS: Total Employees Including Operators2. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCU❑ MOBILE HOME PARK/No. of Spaces3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) ---------- ------ "'3 <br /> i � <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL E] SPA ❑ WADING POOL ❑ NATURAL BATHINf Plu4,��5'pt, i�i�J( tt <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_..-_- -- __-_._--._ APR9 + 1989 <br /> N <br /> Solid Waste Disposal Method <br /> Water Supply Source _ Animal Waste Disposal Method <br /> 6. CONSULTATION FEE _ � � ��.:Jid=l�iAi��fi' <br /> 7. ❑ PLAN CHECKING FEEi5 'CSS <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 prepare this pplication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,and rules re ations of the San Joaquin Local He District. . <br /> APPLICANT'S SIGNATURE X ___ Title ,'� �/� date4&11,17/` r <br /> ! FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1.601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />