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it .. 'W-M®rm. <br /> _ ... <br />• <br /> .YES lf, - <br /> ed When Su A APPLICATION <br /> Completed,Be Su' o Sign The Application. <br /> APPllcation9 Will Be!"; -� <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES IF VEHICLE INVOLVED,GIVE <br /> kNCR.E rN�,ANO 01 fOOD LSTABLISHMENTS.HOUSING %take -- - - <br /> AI Ia Ir,ANr <br /> '1"'o' <br /> Ar+D'rAN PuaLIC POOL5.WATER SAMPLING Llc NO <br /> r IRAr;tuR ANU osi MAL ESTATERegistNo <br /> INSP[CTIONS . ----- - <br /> `. <br /> KE i(AND�Ol' POULTRY RANCHES AND KENNELS ! <br /> +.Ntil:ANO ON MISCELLANEDus SERVICES Color - -- I <br /> '3IIInTIUN <br /> Jt II <br /> t4�__ __ Business/Hardt)To Appcar On flair It <br /> Appl{cation Date _ " - <br /> Type PermlVSelvlCe ReyucslOd' - Address I Tli t3Lci�-_ I)�_ <br /> a AppliLant Name <br /> 1t,tlk ,Otr?IIIt�L- <br /> �Ix1 Emergency Telephone No l <br /> -�} l 7._ L3uslness Telephone No <br /> 1! w / r - <br /> (Property Loc also nlAddress <br /> C L'S-t.�1-:'_ .t'..1+t2- --(?.0-S-a� Addrt:SS <br /> e Property Owner /LL' hu'J_ T ,t Address //. <br /> Operator's NamcCj d frfe a G+?r3! -/Total 6ui dl/g q Dotage Restaurant,Maximum Seating Capacity <br /> T. FOOD ESTABLISHMENTS 1 tt ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> El RESTAURANT 11 FOOD MARKET RETAIL ❑ ICF.PLANT ❑ 13AKERY <br /> ❑ FOOD PROCESSING PLANT 13 COMMISSARY ❑ ITINERANT RESTAURANT <br /> 13 LIQUOR STORE `� BAR ❑ FOOD VENDOR <br /> ED ROADSIDE FOOD STAND 11FOOD SALVAGER ❑ FOOD DEMONS7RA71UN <br /> 0 CONFECTIONARY STORE (3M0131LE FOOD PREP:UNIT ❑ VENDING VEHICLE <br /> 1:1 VENDING MACHINES/No.of - <br /> ❑ FOOD CROP HARVESTING/No.of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ HOTELIMOTELIND,of Units ----- <br /> ❑ MOBILE HOME PARK/No.of Spaces ._ -- <br /> 13 C0 <br /> i <br /> ❑ WATER SAMPLE lBacterialf <br /> g. WATER DUALITY ❑ WATER HAULER ' <br /> ❑ pUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY <br /> NO.OF PUBLIC SERVED(Connections)-------------- _.-- -11 WADING FOUL ❑ NATURAL BATHING PLACE <br /> ❑ SWIMMING POOL ❑ SPA <br /> RECREATIONAL HEALTH ---__- ' <br /> VECTOR CONTROL ❑ POULTRY FARMrMaximum No.of Birds - <br /> /Animal Population No._�--- - No.at Confining Cages -------- <br /> r :ENNEL1Runways --.------__ <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method-------- Animal Waste Disposal Method <br /> Water Supply Source <br /> 6. P_'CONSULTATION FEE <br /> T- ❑ PLAN CHECKING FEE k <br /> a. REAL ESTATE any <br /> Title Comp ..-- �_.- --— -- <br /> ! REQUEST: Water IVell inspection❑ Sample❑ Tele.No <br /> Sewage System inspection <br /> ❑ Address ---- -- <br /> Escrow No.------.. - <br /> Seller Address <br /> Seller -�__-�----- - ,-- <br /> Seller Agent Name <br /> Telephone No. - - - _ <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 /> 1I <br /> ordinances,state laws,and rules and_ . regulations of S iJo uin Local Health District. 1 <br /> Title '�- Date G <br /> APPLICANT'S SIGNATURE q`=�=��i�T `" <br /> FOR DEPARTMENT USE ONLY 1 <br /> ed By <br /> _ DEMIT <br /> Fee 15 Dee:❑ANNUALLY ❑PER UNIT ❑ PER SS7E ❑_EACH T Q_JanuarV t A Receiv S_. DY January]tAMa❑T�O�Et d Rece1CHECKEDY� , <br /> - �—BILLING REMITTANCE REMITTED AMOUNT-�- <br /> EXPLANATION DATE - -�— } <br /> BASE DATE <br /> LES" <br /> Pj;ORAtION — <br /> _r......_...PLU5. .. ..._ _.__.. __._._ ...._. ... .._ -�.-- _.._....._ .._... <br /> r ENA_TY <br /> 7 I <br /> . OTHER <br /> —___�..._ -- Malted - Leriveied <br /> _ i <br /> Plrin,l N,+ Issuance Dale <br /> Oat„ Rrceipl Nu t50t F.HATELTON AVE.,P-0-SO■2099 STOCKTON,CA 95201 <br /> Il Gov+,l Oy <br /> - - RPPUCANT-RETURN ALL COPIES TD' ENVIRONMENTAL HEALTH PEflMIT15E RViCES <br />