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Applications Will Be Processed When Submitted Properly ColYpeted. Be Sure Tf -.gn The Application. <br /> ��`'��' ' APPLICATION <br /> 11g� L� `'Li �-j " RQJMENTAL HEALTH PERMIT/SER*S GENERAL <br /> ENGINEER'S AND/OR j z 1' r1 jIF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/ORft I FOOD ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOR AND/OR H N( 1 J n y REAL ESTATE INSPECTIONS PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR Lic. No. <br /> LICENSE AND/OR I JO I POULTRY RANCHES AND KENNELS Regist. No. <br /> REGISTRATION SAN i, ,r MISCELLANEOUS SERVICES <br /> NUMBER �� '- .t i��; p 'a ' Color <br /> [Application Date 3/10/81 Business/Name To Appear On Permit Animal Hoapi tat <br /> FType Permit/Service Requested: <br /> QApplicant Name john H_ Rowles Address 39 N Ham Lane, T-odiIT CA 9524D <br /> IL <br /> Business Telephone No. Emergency Telephone No. <br /> Property Location/Address 39 N Ham Tana TnAi <br /> aProperty 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 <br /> �Trr KENNEURttnways /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. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <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 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> la <br /> ordinances,state ws, and r sand regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATOR XAR6I e Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:XQ ANNUALLY �ER UNIT ❑ PER SITE ❑ EACH January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE $35.00 1981 3/10/81 due 4/10/81 $35.00 X <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> rn Lyl <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />