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Applications Will Be Prof-essed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> VIRONMENTAL HEALTH PERMIT/SERV. .iES <br /> ENGINE=R S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.MOUSING Make <br /> CONTRACTOR AND'OR PUBLIC POOLS.WATER SAMPLING <br /> 3ROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> r'FNSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> BER Color _ �r <br /> Application Date �� �x� `� Business/Name To Appear On Permit 1 ` Of S'�� �P���� iDi�-�--/ �f� ►1e <br /> „Type Permit/Service Requested: kldt P---1 iYS T <br /> Q Applicant Name �/-wicr tt,-d e-;c Address /,7/0 <br /> a Business Telephone No. 3S d7 Emergency Telephone No. Sc^^t <br /> =Property Location/Address 0-n4.c�- <br /> aProperty Owner r' c ,r 6*cky o,- , Address yk I& <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 ❑ BARP ftESTAURANT <br /> E3 CONFECTIONARY STORE C3 FOOD SALVAGER C3 FOOD DEMONSTRATION tWe R <br /> 13 VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT R VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees n AUG 2 . 1900`� <br /> ALL APPLICANTS: Total Employees Including Operators }{ <br /> 2. HOUSING ►^�II\\'' <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATP'OFI�jQNO N�QL HEALTH <br /> C1 MOBILE HOME PARK/No. of Spaces PERMIT <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 /> F 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 L—L,AP/41,j JZ So 9S/-(- <br /> 7. ❑ PLAN CHECKING FEE <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, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X / Title 5C-1'0- e-eC10_t .s7'- Date Sr��6la� <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiv 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> L J DATE DATE REMITTED AMOUNT <br /> FEE QJ�" J� S� 1� 1rCW f ✓�� <br /> LESS <br /> PRORATION <br /> PLUS �Z- S O <br /> PENALTY <br /> OTHER <br /> OTHER <br /> LA <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 />