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z Applications Will Be Prc :ed When Submitted Properly Completed. Be SL,' �0 Sign The Application. <br /> APPLICATION <br /> ENGINEER'S AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> APPLJCCONTRACTS AND/OR <br /> FOOD ESTABLISHMENTS,HOUSING IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONS <br /> NSE AND/OR POULTRY RANCHES AND KENNELS Lic. No. <br /> 3ERATION MISCELLANEOUS SERVICE- No.--._____ <br /> I. BER � � S Regist. . - <br /> Color <br /> Application Date B� Growe.f vG <br /> �- Busines /Name To Appear On Permit /t'1� '� <br /> FType Permit/Service Requested:.��V r0 'Cilf <br /> u Applicant Name f.rt.6 CA _ Lr-" <br /> ' <br /> _.- +�'OUM�PN��' <br /> - <br /> — wo14P CS 9 y <br /> 0 <br /> oa Business Telephone No. ! D D <br /> aPro ertY Location/Address-1420-0--,400;&V Emergency Telephone Nol r <br /> Jr Property Owner-T,J! � -r0W e/'f r v A <br /> Operator's Name r. [t Address r + 7 �s•� <br /> - Address Prol Bc / 114D�( �� cfj7 9s�s 3 _ <br /> I. 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 <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR 1:1 ITINERANT C1 BAKERY <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR RESTAURANT <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 /> VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> A%w :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. JK CONSULTATION FEE rO <br /> 7. ❑ PLAN CHECKING FEE - <br /> w 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 jthe SanJoaquin Local Health District. <br /> t'LICANT'S SIGNATURE X _ �l s Bvl I p f` Va��ey " rO�rpr �^ <br /> --- Title - f 0,Ctf 0'[O/rds t- Date f <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> .. <br /> FEE — — <br /> LESS <br /> PRORATION I <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receive Date Receipt No. Permit No. Issuance Date Mailed Delivered y <br /> �' APPLLCANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20D9 STOCKTON,CA 95201 I <br />