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Applications Will Be Pro, sed When Submitted Properly Completed. Be Sur-To Sign The Application. <br /> ,%• APPLICATION .,,. <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 /> PPOKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> `� NSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> /iTRATI L}.b3bo MISCELLANEOUS SERVICES <br /> I. .8ER - - -I ( Color <br /> [Application Date h b_ �U Business/Name TO.Appear On Permit <br /> FI Type Permit/Service Requested: �r(t�11.� 11►�SITIQG'4 l � 1�11 <br /> UApplicant Name 1 ,0.^ ► Adddrelss �� —C QSFv�R� A�3 t).Q�urQ CA <br /> d Business Telephone N .RdSTL44 5535 Emergency Telephone No. <br /> a Property Location/Adress � <br /> <Property Owner NA- V-E7od i 7V�C. Address 400 �C 4-k4 - S� - LJJU.1 S <br /> �LOperator's Name 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 /> VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> .ENNEL/Runways /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water S pply Source Animal Waste Disposal Method <br /> 6. L� CONSULTATION FEE P-40�g tk� U.X1ct< tI -, !jkkg�Q <br /> 7. ❑ PLAN CHECKING FEE 110W-iC'pfI <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,Iand rul@s and r the San Joaquin Local Hgalth District. <br /> ATVIk- <br /> PPLICANT'S SIGNATURE XOr 1 ► Title I']7L S Date 6- 6— m <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 S Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE t5 G <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Li 1ko <br /> Received 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 />