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r Applications Will Be Processed When Submitted Properly Completed.Be Sure 019n The Applicaftm <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVIC <br /> ENGINEER'S AND/OR V INVOLVED,GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS ---- <br /> Ir'ENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Re 1St. NO. — <br /> 1. aER Color <br /> (Application Date Business/Name To Appear On Permit North County Landfill. <br /> ,e Type Permit/Service Requested: <br /> Applicant Name SQL gt,llt�C4ldl1 X P4��1L�('141ks— Address 1810 E. Hazelton Ave. . Stkn <br /> aBusiness Telephone No. Emergency Telephone No. <br /> 0-Property Location/Address 17916 E Harney L�ne�Lodi. _ <br /> 4 Property Owner _ — Address T_-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 13 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 OUALITY ❑ 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 /> .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 <br /> 6. M CONSULTATION FEE Solid W - Applicatiov7EW - <br /> 7. ❑ PLAN CHECKING FEE <br /> B. 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 /> 1 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, 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 3/ ❑ July 1 d Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT OUE CHECKED <br /> _ AMOUNT_ <br /> FEE Q,QO--A9/27/89 $500 $60.00 <br /> LESS s e Attaiched <br /> PRORATION A �ry ' 1� <br /> PLUS PENAL 11--*SWILL PENALTY UE A <br /> OTHER DAYS F OM BILLING DATE. Yt , <br /> OTHER <br /> PPrP, «1 nv OR-P Recemn No Parmal No Issuar, .t.) Mailed Delivered <br />