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Applications Will Be Pr ed When Submitted Properly Completed, Be S*o 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 <br /> CONTRACTOR AND/OR REAL ESTATE INSPECTIONS LIC. NO. <br /> BROKER AND/OR POULTRY RANCHES AND KENNELS Reglst. NO. <br /> IrENSE AND/OR MISCELLANEOUS SERVICES <br /> STRATION - CO10( <br /> I, .a ER — <br /> is 9Q S/ r,/ o _ <br /> [Application Date Business/Name To Appe r On Permit <br /> M_.y ._rc lILL� I�dtw1 /J <br /> FType Permit/Service Requested: ,CGLdS G .Qu Sev C �iL I�[ �.° <br /> Z.Applicant Name SQL u ° �'Z""' Gs@�aNAr Address <br /> u 6 Business Telephone No. 9/6—&U-Z//O Emergency Telephone No. <br /> `Property Location/Address Q13� , C <br /> StiOCo _ Address o �dX <br /> c/� , S/o23 G� <br /> `Property Owner a . Address <br /> Operator's Name <br /> Restaurant, Maximum Seating Capacity <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage 11 MEAT MARKET <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL C1 FOOD MARKET WHOLESALE <br /> ❑ COMMISSARY ❑ ICE PLANT 11BAKERY <br /> ❑ FOOD PROCESSING PLANT 13BAR ❑ ITINERANT RESTAURANT <br /> ❑ ROADSIDE FOOD STAND 1:1 LIQUOR STORE 11 FOOD VENDOR <br /> 11 CONFECTIONARY STORE 11 FOOD SALVAGER C1 FOOD DEMONSTRATION <br /> ❑ VENDING MACHINES/No. of <br /> ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ HOTEL/MOTEL/No. of Units <br /> ❑ MOBILE HOME PARK/No. of Spaces ❑ CHEMICAL / <br /> 3. WATER QUALITY 11 WATER SAMPLE (Bacterial) {G mo.J /qL/,, wa�� <br /> 11 PUBLIC WATER SYSTEM 11 SURFACE WATER SUPPLY ❑ WATER HAULER <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 <br /> r :ENNEL/Runways /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Animal Waste Disposal Method <br /> Water Supply Source — <br /> g, ❑ CONSULTATION FEE <br /> 7. ❑ .PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: water Well Inspection[] Sample 13 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 gulatio of the San Joaquin Local Health District. / <br /> APPLICANT'S SIGNATURE X <br /> Title L -10 1 l Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Due: ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 8 ReceiveRdEBylTuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ CHECKED <br /> DATE DATE <br /> Receivep by <br /> Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> 1601 E.HA2ELTON AVE.,P.O.Boz 1009 9TOCKTON,CA 95201 <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES L <br />