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Applications Will Be Pr ssed When Submitted Properly Completed. Be S To Sign The Application. <br /> `✓ APPLICATION 'Nole <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 /> jyCENSE AND/OR POULTRY RANCHES AND KENNELS <br /> "STRATI .__MISCELLANEOUS SERVICES Regist. No <br /> A1117YA9ER _Q3�.6C;� _ Color <br /> -A Application Date IL 2:1j_ t <br /> pp _I Business/Name To Appear On Permits <br /> mType Permit/Service Requested: �ttt yAr� <br /> U Applicant Name CA WliI iAJ E�K-In1l G1 Nl t G NO AT Address 414 I 7L­ <br /> 1fLFf► <br /> Business Telephone No. L415)2B"� 7�1'I Emergency Telephone No. � <br /> a Property Location <br /> /Address.-. 1 l � NAMiItN �_ S1Qlh'F�+ , <br /> _1 Property Owner��Saar(�i — — Address . 7ro smifff 5TAt-TSV47�_IP 05fG7\lTX._ <br /> Operator's Name !Sj kfill;N DN C!A 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 Disposal Method <br /> 6. ❑ CONSULTATION FEE or <br /> 7. ,ErPLAN CHECKING FEEIb� <br /> 8. REAL ESTATE <br /> REQUEST: Water Welllnspection❑ 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, nd rules and regulations of the San Joaquin Local Health District. yy,, <br /> APPLICANT'S SIGNATURE X _ � _ ___ _ Title t0444•.1 <br /> FOR DEPARTMENT USE ONLY <br /> Fee I9 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE SrEACH ❑ January 1 8 Received By January 31 ❑ July 1 R Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE .EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION j <br /> PLUS r <br /> PENALTY <br /> OTHER <br /> OTHER .__.�17 <br /> LR ,—ed by Date Receipt No. Permit.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 />