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Applications Will Be Pr�sed When Submitted Properly Completed. Belo Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> IF VEHICLE INVOLVED, GIVE <br /> ENGINEER'S AND/OR F000 ESTABLISHMENTS.HOUSING Make -- --- <br /> APPLICANT'S AND/OR PUBLIC POOLS,WATER SAMPLING <br /> CONTRACTOR AND/OR REAL ESTATE INSPECTIONS Llc. No. - -- <br /> BROKER AND/OR POULTRY RANCHES AND KENNELS + r' 4 Reg ist. NO. <br /> IrENSE AND/OR ' <br /> STRATION MISCELLANEOUS SERVICER , Color <br /> I. ZER r <br /> Application Date <br /> 0 Business/Nape a To Appear On Permit <br /> f � � <br /> ,Type Permit/Service Requested: 1001 r� / O <br /> Applicant ¢`/ ddress cant Name 5.,.,.�_.l..r..l / A <br /> pp " 9/6–77r2- Or Emergency Telephone No. <br /> D Business Tele hone No. <br /> C OGE <br /> i Property Location/Ad res �'p' �6." S"021 ca. &c z �A <br /> `Property Owner s e / 6i La Address <br /> Operator's Name <br /> S'A,,,I L Address Sn <br /> um Seating Capacityim <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating <br /> MARKET <br /> 11 RESTAURANT El FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE <br /> ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ FOOD PROCESSING PLANT ❑ BAR ❑ ITINERANT RESTAURANT <br /> 11 ROADSIDE FOOD STAND 11 LIQUOR STORE Cl FOOD VENDOR <br /> ❑ CONFECTIONARY STORE 11 FOOD SALVAGER 11 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 <br /> 3. WATER OUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHE❑MICATER HAULER A 1, 1de—f r <br /> ❑ PUBLIC WATER SYSTEM 11 SURFACE WATER SUPPLY <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 No.of Confining Cages <br /> :ENNEL/Runways /Animal Population No. <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Animal Waste Disposal Method <br /> Water Supply Source - <br /> B. ❑ CONSULTATION FEE <br /> 7. ❑ .PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample 11 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 reg Is lions of the San Joaquin Local Health District. <br /> Title Date l <br /> APPLICANT'S SIGNATURE X ��-'��"' <br /> FOR DEPARTMENT USE ONLY <br /> e 31 <br /> Fee Is Due: [1 ANNUALLY [I PER UNIT C1 PER SITE ❑ EACH ❑ January 1 A Received By January 31 July 1 8 Received July <br /> EMIT <br /> BILLING REMITTANCE E AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT_ <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receipt N0. Permit No. Issuance Date Mailed Delivered <br /> Received by Date CA 95201 _ <br /> NEtaLTN PERMIT/SERVICES 1601 E.NA2ELTON AVE.,P.O.sea 2009 STOCKTON, <br />