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Applications Will Be Processed When Submitted Property Completed.Be Sure To Sign The Application. <br /> ®�yAPPLICATIN <br /> ENIITi <br /> R®NGi®/AL HEALTH PERMIT/SERVICES ' <br /> ENGINEER'S AND/OR <br /> APPOC,ANT'S ANO/OR f000 ESTABLISHMENTS.HOUSING 1F VEHICLE INVOLVED,GIVE <br /> CONTRACTOR AND/OR PUBLIC POOL$WATER SAMPLING Make <br /> BROKER ANO/OR REAL ESTATE INSPECTIONS Lic. No. <br /> .DENSE AND/OR POULTRY RANCHES AND KENNELS Regist. NA. <br /> r 3TRATION MISCELLANEOUS SERVICES g <br /> .dER Color ' <br /> [Application Date Z,2- c-- Business/Name To Appear On Permit <br /> HType Permit/Service Requested: <br /> Applicant Name. I�T �^�7 v I i 'NjVl.r[")=1? (Lkic,, 1 i,-)c gAddress 11'03c, <br /> - 11 0)0)f 020 Business Telephone N '20q.S Emergency Telephone No. <br /> aProperty Location/Address -11 '4'Z` 'ri'.O�- `-.' <br /> `Property Owner . 1~.L LII- LD 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 SALVAGERfl 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 p" <br /> ❑ HOTEL/MOTEL/No.of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces <br /> 3. WATER OUALITY ❑ WATER SAMPLE(Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM 13 SURFACE WATER SUPPLY ❑ WATER HAULER It <br /> NO. OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL a SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. 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 /> 8. CONSULTATION FEE r C i��SL�+ t t�s't�r�) - 1,U; _ N t <br /> t. ❑ .PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 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 the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X___ Title RZ b 60 POO"'Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 d Received By January 31 ❑ July 1 Q Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT OUE CHECKED <br /> AMOUNT_ <br /> FEE I, Q ly <br /> LESS - <br /> PRORATION /a <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> A dab <br /> Received by Date Mpt No. Permit No. Issu ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIR ENTAL HEALTH PERMIT/SERVICES 1601 E.HA N AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br />