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Fee Is Due: 0 ANNUALLY <br />FOR DEPARTMENT USE ONLY <br />0 PER SITE 0 EACH 0 January 1 & Received By January 31 0 July 1 & Received By July 31 0 PER UNIT <br />Issuance Dale Mailed Delivered <br /> <br />1601 E. HAZELTON AVE., P.O. Box 2009 STOCKTON, CA 95201 <br />Received by Date Receipt No Permit No <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />BASE EXPLANATION BILLING <br />DATE <br />REMITTANCE <br />DATE <br />S <br />REMITTED AMOUNT DUE <br />REMIT <br />CHECKED <br />AMOUNT <br />FEE $105.00 3 hrs @ $35/ 8/30/89 40-7 $35.00 <br />LESS <br />PRORATION <br />hr <br />-'-Nc.:, —ANTS 3n <br />PLUS <br />PENALTY ii U,./ •-,1- <br />OTHER <br />0,--11 r <br />OTHER <br />IF VEHICLE INVOLVED, GIVE <br />Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />AnerYCetA• <br /> APPLICATION <br />30•--- 72., ENVIRONMENTAL HEALTH PERMITERVICES <br />ENGINEERS AND/OR <br />APPLICANT'S AND/OR FOOD ESTABLISHMENTS. HOUSING <br />CONTRACTOR AND/OR PUBLIC POOLS, WATER SAMPLING <br />BROKER AND/OR REAL ESTATE INSPECTIONS <br />IcENSE AND/OR POULTRY RANCHES AND KENNELS <br />— 420 61);tdk,%5 g <br />3TRATION MISCELLANEOUS SERVICES <br />I. .8ER <br />[Application Date Business/Name To Appear On Permit <br />co Type Permit/Service Requested. 1- <br />1 Applicant Name AfriPri Carl Fnvironmenta]illanagement Address 9719 _Lincoln Village Dr., Suite 501 <br />u 7, Sacramento 95827_ Business Telephone No, Emergency Telephone No a. <br />1 Property Location/Address N W of Daniels St_, Mantera (New Housing Development) <br />.7.1Property Owner Address < - L Operator's Name Address <br />1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br />RESTAURANT 0 FOOD MARKET RETAIL 0 FOOD MARKET WHOLESALE 0 MEAT MARKET <br />FOOD PROCESSING PLANT 0 COMMISSARY 0 ICE PLANT 0 BAKERY <br />ROADSIDE FOOD STAND 0 LIQUOR STORE 0 BAR 0 ITINERANT RESTAURANT <br />CONFECTIONARY STORE 0 FOOD SALVAGER 0 FOOD DEMONSTRATION 0 FOOD VENDOR <br />VENDING MACHINES/No. of 0 MOBILE FOOD PREP. UNIT 0 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 0 CERTIFICATE OF OCCUPANCY <br />MOBILE HOME PARK/No. of Spaces <br />3. WATER QUALITY 0 WATER SAMPLE (Bacterial) 0 CHEMICAL <br />PUBLIC WATER SYSTEM 0 SURFACE WATER SUPPLY 0 WATER HAULER <br />NO, OF PUBLIC SERVED (Connections) <br />RECREATIONAL HEALTH 0 SWIMMING POOL 0 SPA 0 WADING POOL <br />VECTOR CONTROL 0 POULTRY FARM/Maximum No. of Birds <br />r :ENNEURunways /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 />cg) CONSULTATION FEE <br />0 PLAN CHECKING FEE <br />REAL ESTATE <br />REQUEST: Water Well Inspection SampleD Title Company <br />Sewage System Inspection 0 Address Tele. No. <br />Escrow No. <br />Seller <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, and rules and regulations of the San Joaquin Local Health District. <br />APPLICANT'S SIGNATURE X Title Date <br />0 NATURAL BATHING PLACE <br />Review workplan & sampling <br /> <br />Seller Address