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` Applications Will Be Pre"Jqsed When Submitted Properly Completed. Be SurIjo Sign The Application. <br /> APPLICATION <br /> E�/IRONMENTAL HEALTH PERMIT/SERVI�'S <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. �— <br /> IrENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> I, .AER _ _ - _ Color <br /> Application Date a.l_l7 �� Business/NameTo Appear On Permit <br /> rnType Permit/Service Requested:--_ <br /> a Applicant Name Address l p <br /> Z Business Telephone No. -?65 —/o ff Emergency Telephone No.CL <br /> a Property Location/Address__ _l llef <br /> Property Owner_.&f '��s+r Address /��9 �r 4 -4l L Co <br /> a Operator's Name __s7c Y� w no d�" �+ Address /" 9o 4-'- - 4-, , l L C--. ' <br /> ' <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating CapaTcity <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 /> S. VECTOR 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 r�rrc 2/ fdi/6ovr49 <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.. 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 $ ,#3,, n 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 l <br /> T <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Jarivary 31 ❑T��Jpu(1�y,1 c�ved By July 31 <br /> BASE EXPLANATION BG REMITTENCE REM T :`I- Oto AIN'l�1LV=�U.C— CHECKED <br /> DATE <br /> 1 e.p11 . AMOUNT— <br /> FEE -2 --- �� <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> iC - <br /> Recee y to Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APP CANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />