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Applications Will Be Proud When Submitted Properly Completed. Be Sur Sign The Application. i <br /> APPLICATION II <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES - 4 <br /> ENGINEERS 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 AND/OR REAL ESTATE INSPECTIONS - Lic. No. --------. - <br /> CENSE AND/OR POULTRY RANCHES AND KENNELS Regist. No.- -------. 1 <br /> 3TRATION MISCELLANEOUS SERVICES <br /> QDOr -- <br /> I, BER <br /> Application Date. <br /> BBusinlass/N me To Appear On Permit r_ {1 C �__ COYLf70 roJoia EL <br /> w Type Permit/Se ry ice Reglu ested -F•er-F21 s-}_-7_D YLt� fp.DY�IV_1.85_at3_p1-l� `��a=�� O h��i"OYr>7o�1--12.� f$3 <br /> a Applicant Name _1=11J.c-'-.` 0.0-Sgy .D1-aporsl,J_IO-ta,--- Address x1101nUnn`7 tl_� n QrnOn ' <br /> ___ T _ BuBu ess Telephone No.L-� 3_0�,5 . EmergencyVTelephone No •(- - { <br /> a Property LocationI/AId�_d-ress7v-1-rclt ��0'' �- -KLir-4 —. ^ C t <br /> J Property Owner_�310_C_0.�-' C1C?Cp- --- -- Address •el 000 (.VOW C41" CP_. J.Cr�J�S'LCJ O-✓1 `�g - <br /> '�Operator'sName _�I.os.:.w�` Irl 'C¢ Address :3 5r Q CT-�,.Tya I C-4: <br /> i <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 /> 1 <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees --- <br /> ALL APPLICANTS: Total Employees Including Operators 'l <br /> I <br /> 2. HOUSING <br /> 11HOTEL/MOTEL/No. of Units 1) CERTIFICATE OF OCCUPANCY ' t <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> a 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL 1 <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 /> r '.ENNEL/Runways — /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method - -- <br /> Send Waste Disposal Method <br /> Water Supply Source ___ Animal Waste Disposal Method <br /> 6. ❑ CONSULTATION FEE <br /> 7. ❑ .PLAN CHECKING FEE - <br /> B. 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 /> hereby certify that have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws. .fie <br /> APPLICANT'S SIGNATURE X - "N' --'""" Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT it <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNTOUE ' CHECKED <br /> DATE DATE REMITTED AMOUNT Il. <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt N. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa X09 STOCKTON,CA 95201— <br />