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Applications Will Be Pr led When Submitted Properly Completed. Be S, a Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S ANDiOR IF VEHICLE INVOLVED, GIVE <br /> (APPLICANT'S ANDrOR FOOD ESTABLISHMENTS.HOUSING <br /> -TRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING Make <br /> °R AND.,OR REAL ESTATE INSPECTIONS Lic. No. . <br /> +SE AND.,OR POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TRATION MISCELLANEOUS SERVICES g - <br /> dER Color <br /> Application Date 1 a� v 1 Business/Name To Appear On Permit ?DM 5+ro c-a j -LT-ln e,. <br /> ,n Type Permit/Service Requested- Pe.rvh�-r}s or- MQx-1447.',%5 „Js1�5f re.ut'ew- Uf_. icii-k Plw"•S <br /> U Applicant Name Dl�/1 �jtr ,�Ga ,�n.0 Address a Wl- <br /> a Business Telephone No � Og�9�r8 - y 60- Emergency Telephone No, <br /> Property Location/Address a 3aq &)A V.y _DTI'J�P1 <br /> i Property Owner F1 T-E VE"l-O PMe r&M- PAA-)? Address 9 S5?_ o_ .d,..-5tG ratufM JQ.f. g$.Z <br /> Operator's Name PDM 5.fre_Cee- __ Address oZ �Ll �1AV-�l�sly.e* fac kfis 7.C'A-_�9 S 2G b <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 EmployeesALL 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 (Bacteriai) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) <br /> 0 RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> � ECTOR 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 Supply Source _ -__ Animal Waste Disposal Method <br /> 6. ❑ CONSULTATION FEE - <br /> 7. ❑ PLAN CHFCKING 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 d regulations of t an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X - __. Title President —_— Date-5- 12_$9 <br /> FORARTMENT USE ONLY <br /> Fee IS Due: 11ANNUALLY El PER UN17 E] PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 d Received By July 31 <br /> BILLING REMITTANCE $i REMIT <br /> BASE r FXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> F — - <br /> LIFSS <br /> PRO <br /> PLUS <br /> PENALTY <br /> OTHER <br /> + I1 <br /> OTHER I <br /> Rece,�ed by Dale Receipt No Permit ND Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Bow 200 STOCKTON.CA 95201----- <br />