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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> E ONMENTAL HEALTH PERMIT/SERVI GENERAL <br /> ENGINEER'S AND/OR >Si*6MF110 / 0 IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR Si* MF 110YS1 r Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> LICENSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> REGISTRATION MISCELLANEOUS SERVICES <br /> NUMBER FEF IS DUE WITH APPLICATION BEFORE DUE DATE AS SHOAITL <br /> FApplication Date 1/1/82 Business/Name To Appear On Permit N i col aysen Farms <br /> HType Permit/Service Requested: <br /> a Applicant Name N i col aysen Farms Address 23073 S Frederick, Ripon, CA 95366 <br /> Business Telephone No. Emergency Telephone No. <br /> a Property Location/Address 17250 E Dodds Rd , Ripon <br /> d Property Owner Address <br /> L 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 /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ® POULTRY FARM/Maximum No. of Birds 80,000 <br /> ❑ KENNEL/Runways /Animal Population No. No. of Confining C <br /> Sewage Disposal Method RpEnin] <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Disposal Method JAN2 6. 100a <br /> 6. 11 CONSULTATION FEE 0 BUSINESS a ❑ DANCE PERMIT <br /> 7. NVIROMEI�j _ <br /> 11PLAN CHECKING FEE <br /> 8. REAL ESTATE 1=ERMl7�SERVICES <br /> REQUEST: Water Well Inspection 13 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 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 SIGNATU X itle Partner Date ,tan 8, 1982 <br /> FOR DEPAR MENT USE ONLY <br /> Fee Is Due: R ANNUALLY ❑ PER UNIT ❑ PER SITE El EACH January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE $90.00 1982 /1/82 due 1/31/82 $90.00 X <br /> LESS <br /> PRORATION <br /> Plus <br /> PENALTY PENALTIES MILL BE ADD:D AFTER DUE DATE SHQW14 BELC P <br /> OTHER /O O <br /> OTHER 90 DAY!,;-25% of BBAK FEE <br /> I �f3 t,CJ <br /> Received by Datd Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—R 7A: _._F"Fl0NMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />