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Applications Will BePsed When Submitted Properly Completed. Be SuAk.To Sign The Application. <br /> APPLICATION a <br /> ENVIRONMENTAL HEALTH PER <br /> ENGINEEM AND/OR IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> Make <br /> CFrTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> B <br /> OK ER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> .ir'ENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> I. BER Color <br /> Application Date Business/Name To Appear On Permit <br /> oType Permit/Service Requested- <br /> VApplicant Name ORA424-1�_S I'^A-C-44044WE77-5 Address 1';5--3,77 155- A 4 OF ZA I <br /> 09 A Business Telephone Na Lp Wip qov�3 - Emergency Telephone No. <br /> Property Location/Address eLpogAxl� fF5VC_�wi CA- <br /> Property Owner Address 40oll-671 e7�x <br /> LOperator's Name <br /> Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> 0 RESTAURANT 11 FOOD MARKET RETAIL 0 FOOD MARKET WHOLESALE 0 MEAT MARKET <br /> 0 FOOD PROCESSING PLANT 0 COMMISSARY 1:1 ICE PLANT 11 BAKERY <br /> 11 ROADSIDE FOOD STAND 0 LIQUOR STORE 0 BAR 11 ITINERANT RESTAURANT <br /> 11 CONFECTIONARY STORE 0 FOOD SALVAGER 0 FOOD DEMONSTRATION 0 FOOD VENDOR <br /> 11 VENDING MACHINES/No. of 0 MOBILE FOOD PREP. UNIT 11 VENDING VEHICLE <br /> 0 FOOD CROP HARVESTING/No. of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING <br /> 0 HOTEL/MOTEL/No. of Units 0 CERTIFICATE OF OCCUPANCY <br /> 0 MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY 0 WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> 0 PUBLIC WATER SYSTEM 0 SURFACE WATER SUPPLY 0 WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH 0 SWIMMING POOL 13 SPA 11 WADING POOL 0 NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL 0 POULTRY FARM/Maximum No. of Birds <br /> r ' <br /> .ENNEL/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. 13 C9NSULTATION FEE <br /> T. VPLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample 0 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/ules and repulation of�the San Joaquin Local Health District. <br /> — r <br /> APPLICANT'S SIGNATURE X Title A&M4 %?&501-,X� Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: C1 ANNUALLY 0 PER UNIT 0 PER SITE 11 EACH 0 January 1 &Received By January 31 0 July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> OQ <br /> FEE -h30 LAN CH i_c Ic- <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER 'k3S <br /> OTHER <br /> d by Date R I No. Permit No. Issue to Mailed Delivered <br /> ENVIRfNTAL HEALTH PERMIT/SERVICES 1601 E.HAZELVN 201-----J <br /> APPLICANT—RETURN ALL COPIES TO: AVE.,P.O.Box 2009 STOCKTON,CA 95 <br />