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~ -~ Applications Will` Processed When Submitted Properly Completer' Sure TO Sign The Application. <br /> APPLICATIONS }; <br /> ENVIRONMENTAL HEALTH PERMIT/ ERVICES <br /> ENGINEER'S AND/OP .. IF VEHICLE INVOLVED, GIVE <br /> APPLICANTS AND/OR F000 ESTABLISHMENTS.HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BOOKER AND/OR REAL ESTATE INSPECTIONS ! LiC. N0. <br /> NSt AND/OR POULTRY RANCHES AND KENNELS i Regist. No. <br /> 3TRATtON MISCELLANEOUS SERVICES ` <br /> E. .r3ER _ €` Color <br /> 12/7/88Sebastiani Vineyards <br /> Application Date Businees,ss/N Me To pear On Permit <br /> v,Type Permit/service Requested: Ol emeGliatlori Workplan <br /> UApplicant Name Sebastiani Vineyards-5. ManildAiddress� 1X BOX 1290 11 W odbridge, -634 <br /> A <br /> 95258 _ Business Telephone No.{ 209) 339--1311 .-_ Emergency,�Telephone No. 368_ <br /> -,Property Location/Address 4614 W. Tituner Rd. , Loci?!ll CA ?5242- <br /> A Property <br /> 52 12AProperty Owner Sebastiani Vineyards Address see above F <br /> [Operator's Name Sebastiani Vineyards Address see abO rP I <br /> 1. FOOD ESTABLISHMENTS Total Building Sq, Footage Restaurant, Maximum Seatingi Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> li <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT !! ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR II ❑ ITINERANT RESTAURANTr <br /> 11 CONFECTIONARY STORE 13FOOD SALVAGER 11FOOD DEMONSTRATION 13FOOD 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 ,I <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units <br /> ❑ 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 (Connections) 1 <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHkG PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> r :ENNEL/Runways /Animal Population No. No. of Confining Cages �N <br /> Sewage Disposal Method '' M <br /> Solid Waste Disposal Method ` <br /> Water Su�Source Animal Waste Disposal Method M <br /> 6. ;] C� NSULTATION FEE <br /> 7. ❑ .PLAN CHECKING FEE <br /> I <br /> S. REAL ESTATE I� <br /> REQUEST: Water Well Inspection Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <br /> Escrow No. f� <br /> Seller Seller Address <br /> Telephone No. Seller Agent Name <br /> Service Request For Date <br /> I hereby certify that I e prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, stat s, rules and gulations of the San Joaquin Local Health District. <br /> s ���1s' <br /> APPLICANT'S SIGNATURE X Title Adminislrati'le_ 1"1 ifa <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 311 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED jl AMOUNT <br /> ,4 �/?amu«c,J <br /> FEE 77 GcJr�� !sc✓ <br /> LESS <br /> PRORATION 4: l!I <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> e ved by ate Receipt No. Permit No. I Issuance Date ;Mailed Delivered <br /> f <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.OIy Bax 2009 STOCKTON,CA 95201 <br />