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Applications WIII Be Prc sed When Submitted Properly Completed. Be Su To Sign The Application. <br /> .w 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 /> P10KER AND/OR REAL ESTATE INSPECTIONS LIC. No. <br /> NSE AND/ORPOULTRY RANCHES AND KENNELS <br /> /3TRATIQN ']_ �( <br /> � MISCELLANEOUS SERVICES Regist. No. <br /> ` <br /> I. BER - `�S {— Color <br /> [Application Date 6-( -�K Business/Name To Appear On Permit <br /> FI Type Permit/Service Requested: �" I`�c�`Cu�1 t�0ry- {�l XjN, M <br /> i Applicant Name t&(-\U4&oLv,& Ao�ioo Q-,rt AdcQess {0..S�w�clo. Ptd Q �fYI e� I� <br /> Business Telephone No 10S ---,S3.S Emergency Telephone No. <br /> 'a Property Location/Address <br /> <Property Owner 1pZ <br /> & id-S C Address 40-M Si �+ I Z+L MQ <br /> Operator'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 /> WaterrSS pply Source Animal Waste Disposal Method <br /> 6. CONSULTATION FEE t0-0kk- -) 054 RV-- J)WL- eli Z'4-0- <br /> 7. <br /> '4"27. ❑ PLAN CHECKING FEE Locatfto•,-t�t <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 lawn and rules and re ns of the San Joaquin Local Health District. <br /> P <br /> lcca� . Oa <br /> Kk-- r <br /> APPLICANT'S SIGNATURE X TZ C- 0— C>_C-1�cU k 0.1Title F-NJ• M 1 Date 6 - 6- <br /> FOR <br /> - 6-FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 d Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> e--k— �0/�0 ( �,- -q- <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 />