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! ' Applications Will Be P When Submitted;Properly Completed. Be F n To Sign The:Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERV ES <br /> ENGINEER'S AND/OR VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING IiF F VE _ <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING - <br /> RROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> M1ENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> i', 43ER __.. <br /> -----•-• Calor -_ <br /> Application Date L3 8 Business/Name To Appear On Permit City Of Stockton <br /> - - <br /> v)Type Permit/Service Requeste Reyie of ]R�'.��;iminaryv_Ren_rrrt_fnr Fjxe—E -il_C�..—#2, J W Soncx- _ <br /> z< , <br /> Applicant -ock:"t-CITi Address <br /> Business Telephone No. 944_-_828Z____. Emergency`Telephone No. 94q.-8341 <br /> -PropertyLocation/Address ,_-. ,—',onnrn St ,_StnrCt:Gi7� _ --- <br /> Property Owner... <br /> I; :tr tt�ZL---___a::,: _ Address .__��tV Ha��, tOEktf721 <br /> t Operator's Nam C a tz O ._ AddtNs y --� _ <br /> 1. FOOD ESTABLISHMENTS; Dial Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET ETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> 0 FOOD PROCESSING PLANT ❑ COMM SARY ❑ ICE PLANT ❑ BAKERY <br /> ROADSIDE FOOD STAND 0 LIQUOR TORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SAL GER ❑ FOODDEMONSTRATION ❑ FOOD VENDOR <br /> 0 VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> FOOD CROP HARVESTING/No.of Field Employees ' <br /> ALL APPLICANTS: Total Employees Including Operator __-_-•---_-- <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 PA"YM <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER RFC .I it r&0 <br /> NO. OF PUBLIC SERVED(Connections) <br /> 4. RECREATIONAL HEALTH D SWIMMING POOL ❑ SPA WADING POOL © NATURAL BATHING PLACE iUN 61988 <br /> VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Bir <br /> :ENNEL/Runways . - /Animal Population No. : No,of Confining Gages "I LQNME>NTAL HEALTH <br /> Sewage Disposal Method ---------._-_ :. _ EPWI-T SERVICES <br /> Solid Waste Disposal Method_ \nNlo. <br /> Water Supply Source Anie isposai Method6. CONSULTATION FEE �_ W <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 dVDistrict, <br /> San Joaquin County <br /> ordinances,state laws, an ules and regulations t San Joaquin 6ocal Health <br /> APPLICANT'S SIGNATURE ? * � _ Title D� Date 5/31/8 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Clue: ❑ ANNUALLY ER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By.January ❑ July 1&Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BABE EXPLANATION A OUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE D11zle <br /> * -�!,J o <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER. <br /> - <br /> Received by Date Receipt No: Permit No: issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO., :ENVIRONMENTAL HEALTH:PERMITJSERVIGES 1601.E.HAZELTON AVE.,P.O.:Box 2009 STOCKTON...CA.95201 <br />