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Applications Will BePr ed When Submitted Properly Completed. Be' To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVI <br /> ENGINEER'S AND/OR VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOU <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPE C;A E I OE e <br /> BROKER AND/OR REAL ESTATE INSPECTIONS No. <br /> .ir.ENSE AND/OR POULTRY RANCHES AND KENN <br /> 3TRATION MISCELLANEOUS SERVICES <br /> I, .aER OCT 21 ReglSt. N0. <br /> Color <br /> ENVIRONMENTAL HEALTH <br /> rApplication Date Business/Name To Appear On Permit IT ER AIT® ERVICEc <br /> oType Permit/Service Requested: — <br /> 4Applicant Name %If ress 1465 S Lincoln St ;—Stockton 95206 <br /> J Business Telephone No. Emergency Telephone No. <br /> ,,Property Location/Address Matlth2,y Rd , $tOCktOn <br /> aProperty Owner Address <br /> Operator's Name Address <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 /> ❑ FOOD CROP HARVESTING/No.of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units ❑ 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) <br /> 4s RECREATIONAL HEALTH ❑ SWIMMING POOL ® SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum'No. of Birds <br /> r .ENNEL/Runways /AnimalPopulation No. No.of,Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> 6. CC CONSULTATION FEE' Solid Waste_ 5 Year Permit <br /> T. ❑ .PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> h <br /> REQUEST: WateiWell Inspection❑ Sample 11 Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <br /> Escrow No. <br /> Seller Seller Address <br /> Telephone No. Seiler Agent Name <br /> Service Request For Date <br /> I hereby, certify that 1 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&Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOU T DUE CHECKED <br /> G AMOUNT <br /> FEE O' 89 $525. <br /> LESS 41 <br /> PRORATION <br /> PLUS <br /> PENALTY TO <br /> ' <br /> PAW <br /> OTHER - <br /> UE ACC N14 JU <br /> QM BILLING DA19, <br /> OTHER <br /> i '� s <br /> Received by Date Receipt No. Permit N Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201 <br />