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egist. No <br />Color <br />Fee IS Due: 0 ANNUALLY 0 PER UNIT 0 EACH 0 January 1 & Received By January 31 0 July 1 & Received By July 31 0 PER SITE <br />Issuance Date Mailed Delivered <br />1601 E. HAZELTON AVE., P.O. Boa 2009 STOCKTON, CA 95201 <br />Received by Date Receipt No Permit No <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />FOR DEPARTMENT USE ONLY <br />BASE EXPLANATION BILLING <br />DATE <br />REMITTANCE <br />DATE <br />$ <br />REMITTED AMOUNT DUE <br />REMIT <br />CHECKED <br />AMOUNT <br />FEE <br />pC.. <br />#3,5 --3.... ,c.2 41461/114-- 8/30/89 $35.00 <br />LESS <br />PRORATION <br />PLUS <br />54/Z TOgehi, <br />PENALTY RENALTIT_c_. <br />OTHER DAYS FROM <br />\,',11I.'._ --,.:) H 7-, 74 .. ._, FAST <br />BILLING 1.),AIL <br />r, , U E ACCOUNIS 30 <br />OTHER <br />ENGINEER'S AND/OR <br />APPLICANT'S AND/OR <br />CONTRACTOR AND/OR <br />BROKER AND/OR <br />IrENSE AND/OR <br />3TRATION <br />I. .BER <br />Applications Will Be Processed When Submitted Properly Completed. Be cure To Sign The Application. <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />FOOD ESTABLISHMENTS. HOUSING <br />PUBLIC POOLS. WATER SAMPLING <br />REAL ESTATE INSPECTIONS <br />POULTRY RANCHES AND KENNELS <br />MISCELLANEOUS SERVICES <br />[Application Date Business/Name To Appear On Permit <br />ui Type Permit/Service Requested' <br />Tr Applicant Name ___Arie-RicAti___.G94,42441,4161.1,7: Address -t ItIVe_S__A-rwl+-,6_ , ._ <br />(,' __,„<e9c/0_,, ef, • ,3-eZ_ Business Telephone No Emergency Telephone No <br />tr Property Location/Address / W 41/it/7-6,-C Coe/ I/ --/ ' /6/47frra 1 1 <br />Properly Owner BeCk. Sg we 1 - 0, ftle"Air CO • Address 2/lie 4). rri/x/Afe72-• <br />g&Z-C -[ Operator's Name A • It). <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 0 NATURAL BATHING PLACE <br />VECTOR CONTROL 0 POULTRY FARM/Maximum No. of Birds <br />r ENNEL/Runways /Animal Population No. No. of Confining Cages <br />Sewage Disposal Method <br />Solid Waste Disposal Method <br />Water 9,kpply Source Animal Waste Disposal Method <br />a CONSULTATION FEE 0/ <br />0 PLAN CHECKING FEE <br />REAL ESTATE <br />REQUEST: Water Well Inspection El Sample 0 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 />Address <br />Seller Address