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Ali-, Applications Will Be Proces hen Submitted Properly Completed. Be Sure T 0 <br /> n The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ,F,NGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> hPPL1CANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING Make -- <br /> APPLICACT*S AND/OR PUBLIC POOLS.WATER SAMPLING <br /> BROKER AND A REAL ESTATE INSPECTIONS Lic. No. <br /> BROKER <br /> AND/OR POULTRY RANCHES AND KENNELSir. Reg ist. No. ------- <br /> 3TRATION PROGRAM UGST MISCELLANEOUS SERVICES <br /> Color <br /> I. .8ER ----------------- <br /> Application Date-10-23-9.Q_ Business/Name To Appear On Permit-- <br /> WType Permit/Service Requested:-- <br /> Address— <br /> equested: — <br /> z. Applica t Name . h��.1 Olt C_ om Inv Address— P O Box 4021 <br /> �oncor , CA 94524 — Business Telephone No. Emergency Telephone No. <br /> a Property Location/Address_ <br /> 3725 Tracy Blvd. , Tracy CA 9576 <br /> <Property Owner _ Address <br /> Address <br /> Operator's Name — <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 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 C1 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 /> 5. 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 /> Animal Waste Disposal Method <br /> Water Supply Source <br /> 6. ❑ CONSULTATION FEE See Attached <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 San Joaquin 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 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdE July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE $262.50 Inspecti s 12-7-9 <br /> LESS <br /> PRORATION <br /> i <br /> PLUS $26 . 25 Penalt $288. 75 <br /> PENALTY <br /> OTHER — — <br /> OTHER AOL <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> . APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95209 <br />