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Applications Will Be Pr ed When Submitted Properly Completed.Be o Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> NEER'S AND/OR IF VEHICLE INVOLVED,GIVE <br /> {CANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make <br /> NTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> ROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> .ir.ENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist.NO. <br /> r; ,AERColor <br /> Application Date Z 72— '7Qnn Business/Name To Appear On Permit <br /> FI Type Permit/Servi ee Requested: <br /> lAgplicantNameO0__! V L tJ I t I C Address 111 340 w 8117f` — [ //0 <br /> J l� 4 Business Telephone No. 1 -ZOT, Emergency Telephone No. <br /> a Property Location/Address ( � <br /> aProperty Owner . QLL_ Address <br /> Operator's Name Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Seating Capacity <br /> RESTAURANT 0-FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> O: 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 ^T <br /> 2. HOUSINGe <br /> ❑ HOTEL/MOTEL/No. of Units 11 CERTIFICATE OF OCCUPANCY.!. I <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) 0 CHEMICAL <br /> 'PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) !WIT <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA WADING POOL ❑ NATURALBATHI isavICES <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 /> B. g CONSULTATION FEE <br /> T. PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample[] Title Company <br /> Sewage System Inspection 0 Address Tele. No. <br /> Escrow No. <br /> Seiler Seller Address <br /> Telephone No. Seller Agent Name <br /> Service Request For Date <br /> I hereby certify that 1 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 Joe in Local Health District. <br /> Ar <br /> APPLICANT'S SIGNATURE X Title IN Date <br /> FOR DEPARTMENT USE ONLY ; <br /> Fee IS Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1&Received By July 31 <br /> REMIT <br /> BASE EXPLANATION <br /> BILLING REMITTANCE $ <br /> AMOUNT DUE :CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ENAL T€ES 4, 16!_(_Bim APIC)LIED TO PAST DUfACCOUNTS1,91 <br /> �}( <br /> L - 0 T <br /> OTHER '' 4,o <br /> OTHER 3/30189 1 / � <br /> a <br /> Received by Date Rece No. Pe mr o. Issuance Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2M STOCKTON,CA 96201 <br />