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i <br /> Applications Will Be Pr 'sed When Submitted Properly Completed. Be 5�` o Sign The Application. <br /> - <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH ERMIT/SERVICES <br /> 6NGINEtRS AND/6R IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,I OUSING Make <br /> CONTRACTOR AND/OR PUBLC PO I.S.WATER SA PAYMENT REALI STATE INSPECTIONSPLING Lic. No. <br /> BROKER AND/OR <br /> ir.FNSE AND/OR R E C E f V E Q POULTRY <br /> RANCHES <br /> S AND KENNELS Regist. No. <br /> 3TRATION <br /> i, BER Color <br /> MAY I D isu <br /> ect <br /> [Application Date , B S Business/Name To Appear On Permi C � <br /> FI ypm�enrrit/Service Reques t N 8S Cry ) Q C q,0 S `ruh G` f �.,ti 1 <br /> Z Applicant Name . Address �u o Aikameda. dP Jcc.� Pajaa.5 <br /> Z_ San qe3 CA Business Telephone No 441-0 Emergency Telephone No. <br /> as Property Location/Address _I k0lf__ a- _k6,4A CA_ <br /> aProperty Owner�rr� P- pdych) Address -1 n'� W'4.- (e tin P�.c get • -W o� C+ <br /> "Operator's Name Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. f=ootage 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 /> 5. 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 /> Water Supply Source Animal Waste Disposal Method <br /> 6. % CONSULTATION FEE 1J lQ Ky712 vcCay IL <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection[] SampleD 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 thework 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 /> 413a Afs cs IV00 F <br /> APPLICANT'S SIGNATURE X(al�)� Q'rplYA 1,0 itle P�0 CQ Date �� I For <br /> FOR DEPARTMENT L SE ONLY <br /> Fee 15 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMP TANCE $ AMOUNT DUE CHECKED <br /> DATE D TE REMITTED AMOUNT_ <br /> FEE �� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ved 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 45201 <br />