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Applications Will Be P"-essed When Submitted Properly Completed. Be �e To Sign The Application. <br /> t %%W APPLICATION %.I <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER ANOtOR REAL ESTATE INSPECTIONS L;c. No. <br /> +r'FNSE ANDIOR POULTRY RANCHES AND KENNELS Regist. No,... <br /> STRATION MISCELLANEOUS SERVICES g <br /> I. aER -- - Color --- - - -. <br /> 'Application Date fl Busine$s/Name To Appear On Permit <br /> a,Type Permit/Service Requested: 1tP Q7Cc'c Ew 1OfPL' "'. ]�� �'t'v Pull_C-A hzzrN<,e <br /> i Applicant Name .21-No-e .40ir'l-7 Addrdss- 3W__�✓__ c3�1 � 71� -4_ <br /> U <br /> Q. Business Telephone No.-,20-9-1-296 - �6.4.� _ Emergency Telephone NO. �:_3M1-$_� <br /> 'Property Location/Address '191 (l lam .] ___ t1Cbf+rltl _C� [ 720 <br /> i PropertyOwner JAN e- Lam_ P�.� r 22 C7 <br /> - -_ T�ct'sf_ .. Address -- -1 �— ._-- <br /> LOperator's Name Address <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 /,t,„t <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units -._ - -_. —_ ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces __ .i ,r * �� <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER w, <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 /> r MNNEL/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 /> 6. C3 SASULTATION FEE - -- -. - - -- --� <br /> 7. VPLAN 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 C` I — .. _. Title O�4V Date <br /> DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 B Received By January 31 ❑ July 1 G Received By July 31 <br /> .�.T__._.__„ - �— REMIT <br /> BILLING ` REMITTANCE $BASE EXPLANATION DATE 4 DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <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 PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />