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OrSF- D1r4tplications Will Be rssed When Submitted Properly Completed. Be To Sign The Application. # rL <br /> APPLICATION <br /> ENGINEER'S AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> APPLICANT'S AND/OR f000 ESTABLISHMENTS.HOUSING IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/Ofl PUBLIC POOLS, WATER SAMPLING Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONS <br /> .Ir•.E 3TR AND/OR POULTRY RANCHES AND KENNELS1. LiC. No. - <br /> .BER ATION MISCELLANEOUS SERVICES Regist. No. <br /> rotor <br /> (Application Date 9'2�= Business/Name To Appear On Permit <br /> Type Permit/Service Requested- <br /> l­ ____ —.- J.., -- -- <br /> i Applicant Name _ � �-_ _. Address LLL3 tly— 14 1 �-ET m y� (Tr <br /> LA olou `�1Zo � el - <br /> u --f Business Telephone No.- _ _ - Emergency Telephone No. <br /> 'a Property Location/NA�1d-d rens_L�N_•_�II.]LL�fL` -- <br /> aProperty Owner�r 1ft1�LE.'��RJ LLIJ(�- tJ. ._, _� Address- _ <br /> LOperator's Name Address _ <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT 11 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 - <br /> PAY <br /> 2. HOUSING -- PEC MEET <br /> 11HOTEL/MOTEL/No. of Units EIVEp <br /> ❑ CERTIFICATE OF OCCUPANCVnll�i� <br /> 11 MOBILE HOME PARK/No. of Spaces Er; 988 <br /> 3. WATER DUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL 'ENVIRON <br /> 11 PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER FE MENT, <br /> NO. OF PUBLIC SERVED (Connections) _ NITISERVI HEALTH <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 /> Solid Waste Disposal Method <br /> Water Supply Source �'�� �. , y�- Anima Waste Dispos I Method <br /> 6. CONSULTATION FEE •- 1 ulfef � Y 6163 �M I7- <br /> 7. .PLAN 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 <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 Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 A Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNTDUE CHECKED <br /> AMOUNT <br /> FEE _ <br /> LESS •V v 9 , z <br /> PRORATION <br /> PLUS <br /> PENALTY ^ <br /> OTHER �• T- <br /> OTH /^ o <br /> U" Ff�gNI <br /> Received by Dale Receipt No Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2ELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />