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` Applications Will Be Process When Submitted Properly Completed. Be Sure To ign The Application. W APPLICATION ENVIRONMENTAL HEALTH PERMIT/SERVICES ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make ------- CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING REAL ESTATE INSPECTIONSBROKER �} ,J� BROKER AND/OR POULTRY RANCHES AND KENNEUB-V U LAST BAY DI51;c. NO. ----- IrFNSE AND/OR Regist. __—__-.-- 3TRATION PROGRAM UGST MISCELLANEOUS SERVICES Color _-- I. .dER -------------_.-------- JAN 1 4 1991 rApplication Date_l�_ __ Business/Name To Appear On Permit --------- ------------ - IoType Permit/Service Requested:--------- Box equested: -- --- ---------- a Applic�pt Name __ Sh�l- -�-L-Coffin --- ---- Address---R-0, Box 4021 v C;oncorc�CA 94524 Business Telephone No. --- Emergency Telephone No. 1,LPropertyLocation/Address 3725 Tracy Blvd , Tracy, CA 95-376 — J Property Owner — _._ —__ Address Address - [Operator's Name - 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity ❑ RESTAURANT ❑ FOOD MARK T RETAIL ❑ FOOD MARKET WHOLESALE C1MEAT MARKET ❑ FOOD PROCESSING PLANT ❑ CO MISSARY ❑ ICE PLANT ❑ BAKERY ❑ ROADSIDE FOOD STAND ❑ LIQLNOR STORE ❑ BAR ❑ ITINERANT RESTAURANT ❑ CONFECTIONARY STORE ❑ FOOIJ,.SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE ❑ FOOD CROP HARVESTING/No. of Field Empt yees — --ALL APPLICANTS: Total Employees Including O rators 2. HOUSING 11HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY ❑ MOBILE HOME PARK/No. of Spaces 3. WATER QUALITY ❑ WATER SAMPLE (Bacteria ❑ CHEMICAL T C3 PUBLIC WATER SYSTEM 11 SURFACE WATER S PLY 11 WATER HAULER PAYMENT NO. OF PUBLIC SERVED (Connections) !'► 4. RECREATIONAL HEALTH 11 SWIMMING POOL ❑ SP ❑ WADING POOL 13 NATURAL BAT �ppqg#i99,, 5. VECTOR CONTROL C1 POULTRY FARM/Maximum No. Birds - �Ep .ENNEL/Runways _—. /Animal Population No. No.of Confining Cages U�IY 5 S+yIF Sewage Disposal Method P HEA�- Solid Waste Disposal Method imal Waste Disposal Meth Water Supply Source 6. ❑ CONSULTATION FEE See Attached 7. ❑ PLAN CHECKING FEE 8. REAL ESTATE REQUEST: Water Well Inspection Sample❑ Title Company Sewage System Inspection ❑ Address Tele. No. Escrow No. Seller Seller Address Telephone No. Seller Agent Name — Service Request For Date I hereby certify that I have prepared this application and that the work will be done`►�accordance with San Joaquin County ordinances,state law and ul S and regulations of the San Joaquin Local Health Distrl . APPLICANT'S SIGNATURE Title IV, Date FOR DEPARTMENT USE ONLY Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January El July 1 &Received By July 31 REMIT BASE EXPLANATION BILLINGFREMITTANCE $ A LINT DUE CHECKED DATEREMITTED AMOUNT FEE $262 .50 Inspecti s 12-7-9 LESS PRORATION PLUS $26 .25 Penalt $288 ' 75 PENALTY OTHER 1 OTHER 4, t. Received by Date Receipt No. Permit No. I1suance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: EN ONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201