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Applications Will Be*4 d When Submitted Properly Completed. Be Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/oR 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 /> .Ir'ENSE AND/OR POULTRY RANCHES AND KENNELS <br /> u- 3TRATION Unit II MISCELLANEOUS SERVICES Regist. No.._-.__ <br /> i. BER ---- Color --. --.— — --.-__—.._ <br /> i Application DateBusiness/Name To Appear On Permit —_FOY'Wcird ._Transfer St1t� <br /> (nTYpe Permit/Service <br /> a Applicant Name FOYWcdrCl Z`nm- safer Station - -_- Address---__ <br /> Business Telephone No._______—_-_--_ _ Emergency Telephone No. <br /> -Property Location/Address <br /> a Property Owner_ �— ___— --____.. Address -Y-.-O --�OX6,336, Stockt— rA 95206 <br /> - <br /> -LOperator'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 0 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 11 WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds — <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 ft <br /> 6. JEJ CONSULTATION FEE SOlid Waste — <br /> T. ❑ .PLAN CHECKING FEE <br /> 6. REAL ESTATE j 4 <br /> REQUEST: Water Well Inspection Sample❑ Title Company QA it, ' r <br /> Sewage System Inspection ❑ Address P (Ibl.rn.,y,._. <br /> Escrow No. -- -- uvv'R® �f►VTAL HEASLTHE V ors � -- <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. <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 8 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE 636.00 see attached 12/28/90 /!;636 0 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER PENALTIES kAtILL BE APPLIED .- T DI— <br /> i <br /> OTHER '�-�' �'�°"� a"=3ii..L�N � .. _E — <br /> . <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 />