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Applications Will Bel 1W ed When Submitted Properly Completed.Be*o Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PER <br /> ENGINEER'S AND/08 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 /> .IrENSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TRATION MISCELLANEOUS SERVICES <br /> 1, BER Color <br /> U <br /> (Application Date k, Business/Name To Appear On Permit 15 La <br /> Type Perm it/Sern'ce Requestetit:-ly <br /> kl._. <br /> Z A Rpkcant Address N <br /> :5 �caC40r -! Business T ephon N�q_449(,7 Emergency Te?ephone N <br /> Property LocatiofW.,Addres -4- Ll in C_C>I V1 C>0" ��- c A hn, C4 <br /> d Property Owner Address"Ll 01 S 4 CA <br /> Lj <br /> Operator's Name Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> 11 RESTAURANT 11 FOOD MARKET RETAIL 0 FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> 13 FOOD PROCESSING PLANT ❑ COMMISSARY 11 ICE PLANT 11 BAKERY <br /> 11 ROADSIDE FOOD STAND ❑ LIQUOR STORE 11 BAR 13 ITINERANT RESTAURANT <br /> 0 CONFECTIONARY STORE ❑ FOOD SALVAGER 0 FOOD DEMONSTRATION 11 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 0?N PANCY <br /> 11 MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY 11 WATER SAMPLE (Bacterial) CHEMICAL <br /> 11 PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY 13WATER HAULS <br /> NO. OF PUBLIC SERVED (Connections) 0 <br /> 4. RECREATIONAL HEALTH 11 SWIMMING POOL 11 SPA 11 WADING POOL ❑ z BAT�146?g,h LACE <br /> 5. VECTOR CONTROL POULTRY FARM/Maximum No. of Birds <br /> r <br /> .ENNEL/Runways —_ /Animal Population No. No. of Confining <br /> Sewage Disposal Method /�P h, <br /> '0 -7 <br /> Solid Waste Disposal Method <br /> Water Supply Source — Animal Waste Disposal Method <br /> 6. 0 CONSULTATION FEE <br /> T.'P PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection 0 Sample[3 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 Court <br /> ordinances, state laws, and rules andgulations of thb San Joaquin Local Health District. ref <br /> APPLICANT'S SIGNATURE Titl Date <br /> L/ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: El ANNUALLY 0 PER UNIT 0 PER SITE 0 EACH 0 January I &Received By January 31 0 July 1&ReCAe By July 31 <br /> R MIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE HI KED <br /> AMO <br /> DATE DATE REMITTED �AMO INT <br /> FEE <br /> ag-Ij r- 01 �A� OLE '510,Iof ID In q5? <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Dat, IReipt No. Permit No. Is S Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENV MENTAL HEALTH PERMIT/SERVICES 1601 E.H ON AVE.,P.O.Box 21709 STOCKTON,CA 95201 <br />