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~ Applications Will Be Pro*d When Submitted Properly Completed. Be Su Sign The Application. <br /> 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 /> NTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING <br /> KER AND/OR REAL ESTATE INSPECTIONS Lic. No. — <br /> _NSE AND/OR POULTRY RANCHES AND KENNELS Reg iSt. No.- -------- <br /> iTRATION MISCELLANEOUS SERVICES <br /> Color <br /> I. .dER --------------- <br /> (Application Date '1/-9-0— Business/Name To Appear On Permit --- <br /> ,AType Permit/Service Requested: -------- <br /> <Applicant Name FxPI t-Pr•h _— Address—41674 Christy STreet - <br /> J Fremont, 94538-3114_ Business Telephone No. Emergency Telephone No. <br /> a <br /> a Property Location/Address_ 3555 W Hammer Lance, Stl1C ktAri <br /> aProperty Owner _ __ Address <br /> -LOperator'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 /> RECREATIONAL HEALTH ❑ SWIMMING POOL 13 SPA ❑ WADING POOL 11 NATURAL BATHING PLACE <br /> *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 <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.— Seiler 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 Date <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 July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 2Q Eq <br /> Q— DATE REMITTED AMOUNT_ <br /> FEE <br /> LESS <br /> PRORATION <br /> PPLUS <br /> ENALTY $10 .50 Penalty 1/9/91 $115 .50 <br /> OTHER <br /> OTHER _ <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> _,-„-� ,----,•--, �,•–.v or x•••�rcpwrr Pr 1601 E HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />