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Application* WIN Be processed When Submitted Properly Completed. BeSu,,Mo Sign The Application. <br />1"I APPLICATION <br />E Ir <br />IFIONMENTAL HEALTH PERMIT/SERVICES <br />ENGINEER'S AND/OR <br />APPLICANT'S AND/OR <br />CONTRACTOR AND/OR <br />BROKER AND/OA 1,X AJT <br />.irrNSE AND/OA <br />3TRAVON <br />1, .8EA — <br />FOOD ESTABLISHMENTS, HOUSING <br />PUBLIC PINILS, WATER SAMPLING <br />REAL ESTATE INSPECTIONS <br />POULTRY RANCHES AND 111111111.3 <br />MISCILLAME608 SERVICES <br />Application Date ?!!;::2f —2V Business/Name To Appear On Permit <br />IF VEHICLE INVOLVED, GIVE <br />Make — <br />Type Permit/Service Requested: . Ze2 <br />Applicant Name AC- Address 7;2:?h <br />Business Telephone No. Emergency Telephone No. <br />Property Location/Address <br />`Property �dd <br />Property Owner '49 Za �y sy, <br />9 - —VKI�—ress <br />[Operator's Name — Aelfirac*Q <br />I• Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br />11 RESTAURANT ❑ FOOD MARKET RETAIL ' 0 FOOD MARKET WHOLESALE 13 MEAT MARKET <br />0 FOOD PnocegsING PLANT <br />13 COMMISSARY <br />0 ICE PLANT <br />0 BAKERY <br />11 ROADSIDE FOOD STAND <br />0 LIQUOR STORE <br />13 BAR <br />0,1TfNERANT RESTAURANT <br />1:1 CONFECTIONARY STORE <br />0 FOOD SALVAGER <br />1:1 FOOD DEMONSTRATION <br />/E3 FOOD VENDOR <br />13 VENDING MACHINE9/Nb. of <br />—��o -- <br />11 MOBILE FOOD PREP. UNIT <br />/ U VENDING VEHICLE <br />El FOOD CROP HARVESTING/No. of Field Employees <br />ALL APPLICANTS: 'Total Employees Including Operators <br />2. HOUSING 4Cl 47� A5,-ae <br />0 HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br />13 MOBILE HOME PARK/No. of Spaces <br />3. WATER OUALITV 13 WATER SAMPLE (Bacterial) ❑ CHEMICAL <br />11 PUBLIC WATER SYSTEM - 0 SURFACE WATER SUPPLY 13 WATER HAULER <br />NO. OF PUBLIC SERVED (COhneCtIOM§) 1 <br />A. RECREATIONAL HEALTH 0 SWIMMING POOL 13 SPA 13 WADING POOL 0 NATURAL BATHING PLACE <br />S. VECTOR CONTROL 0 POULTRY FARWMaximUm No. of Birds <br />r ' <br />.ENNEL/Runways — /Animal Population No. No. of Confining Cages <br />Sewage Disposal Method <br />Solid Waste Disposal Method <br />Water Supply Source —_ <br />S. 13 - CONSULlrAMN FEE <br />V. 0 PLAN CHECKING 1`99 <br />S. REAL ESTATE <br />REQUEST: Water Well Inspection 0 Samplet! <br />Sewage System Inspection,.. 0 <br />Escrow No. <br />Seller <br />Telephone No. <br />Service Request For Date <br />Animal Waste, Disposal Method <br />Title Company <br />Address <br />Seller Address <br />Seller Agent Name — <br />Tale. No. <br />j 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 <br />Title <br />Date <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: 0 ANNUALLY 0 PER UNIT 13 PER SITE 13 EACH 0 January I & Received By January 31 ❑ July 1 & Received By July 31 <br />BASE <br />EXPLANATION <br />Bill LINGREMIT <br />REMITTANCE <br />$ <br />AMOUNT DUE <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />—��o -- <br />AMOUNT <br />FEE ' 00 <br />02FA �* <br />01 er,:Ilt <br />-115le <br />---911-8L9Q-1 <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />Received by Date Receipt No Permit No. Issuance Date Mailed Delivered <br />APPLICANT— RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SlINVICits 11.00111. HAZELTON AVE., P.O. Sox 2009 STOCKTON, CA 952011— <br />