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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> IRONMENTAL HEALTH PERMIT/SERVI <br /> ENGINEER'S AND/ORIF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR ' i `" FOOD ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR r' ..° REAL ESTATE INSPECTIONS Lic. No. <br /> .Ir'ENSE AND/OR POULTRY RANCHES AND KENNELS Regist. NO. <br /> 3TRATION p " MISCELLANEOUS SERVICES g <br /> I. BER A— Color <br /> (Application Date B siness/ T ' arO er it <br /> u)Type Permit/Service R tLeA <br /> a Applicant Name Ades. L?. <br /> S1 �i✓ <br /> I Business lepho a r6144 2f Emergency Telephone No. <br /> aProperty Location/A cess <br /> a Property Owner m Address <br /> 54 <br /> -[Operator's Name Address Q <br /> 1. FOOD ESTABLISHMENTS a Total Building Sgoota Restaurant, Maximum Seating Capacity <br /> 11 RESTAURANT ❑ FOOD MARKET RETAIL FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> C1 FOOD PROCESSING PLANT ❑ COMMISSARY C1 ICE PLANT C1 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 /> f, w <br /> ALL APPLICANTS: Totilmployees Including Operators <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units ❑ 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 (Gonne. Ions) " <br /> 4. RECREATION 4 EALTH SWIMMING POOL ❑ SPA7 .❑' ADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTR tr P POULTRY,,FARM/Maximur4No of Birds , <br /> :ENNEL/Runways /Animal Population No. m Nlo: df Confining <br /> 7. <br /> Sewage Disposal Method T1 <br /> Solid Waste Disposal Method..': <br /> ethod` <br /> Water Supply Source _ Animal Waste Disposal Method <br /> 6. ❑ e6NSULTATION FEE _ <br /> T. Ef.PLAN CHECKING FEE 72 Z J <br /> f 8. REAL ESTATE <br /> j REQUEST: Water Well Inspection Sample[] Title Company <br /> System Inspection ❑ Address Tele. No. <br /> Escrow No.'- <br /> Seller <br /> o Seller __ s <br /> Telephone No Seller AcjentNar►ie <br /> Servicg Rgqost F*teNI hereby certify thatthis application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laegulaticlns of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X Titlef Date <br /> I FOR DEPARTMENT USE;ONLY <br /> i <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE i <br /> LESS 1`ir <br /> PRORATION <br /> PLUS <br /> PENALTY ; •v's: <br /> OTHER <br /> +n <br /> OTHER C-0 <br /> Received by Date ipt No. Permit No. Issu ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />