FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

ENGINEER'S AND/OR APPLICANT'S AND/OR CONTRACTOR AND/OR BROKER AND/OR IrF_NSE AND/OR 3TRATION I, c3ER -- -. - . -- - Applications Will Be Prcicesser�en Submitted Properly Completed. Be Su To Sinn The Application. .1,Ole ENVIRONMENTAL HEALTH PERMIT/SERVICES LVED GIVE F000 ESTABLISHMENTS. HOUSING PUBLIC POOLS. WATER SAMPLING REAL ESTATE INSPECTIONS POULTRY RANCHES AND KENNELS MISCELLANEOUS SERVICES IF VEHICLE My Make--------- Lic. No. - - - --- Regist. No. _ Color ._ f Application Date Business/Name To Appear On Permit u,Type Permit/Service Requested: - .$vii `Applicant Name UjZrfi 1. �wG r - -- Address _ _ _-- u_ _ Business Telephone No. ILS-' 1 � - Emergency Telephone No. l i Property Location/Add'''ress_ 1�� � Property Owner __& V_yv l� c� ---- - Address C � CJ � lsl Operator's Name �`)Lt�yt [rL� ----- Address _ 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE 1:1 MEAT MARKET ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR ❑ VENDING MACHINES/No. of -_ ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE ❑ FOOD CROP HARVESTING/No. of Field Employees ------ PAYIN12:u ALL APPLICANTS: Total Employees Including Operators - ----- - I : ❑ C E I 11 / ` D 2. HOUSING 11HOTEL/MOTEL/No. of Units ❑ig�TIFICAIOFiOCCUPANCY ❑ MOBILE HOME PARK/No. of Spaces - 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) 15 CHEMICJWVi'0NML:N f AL HLTALTH ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER`1At�llf fj�?�/irF� NO. OF PUBLIC SERVED (Connections) --- - -- ----- - 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds .ENNEL/Runways /Animal Population No. -. No. of Confining Cages Sewage Disposal Method - - Solid Waste Disposal Method Water Supply Source _ _ Animal Waste Disposal Method 6. ❑ CONSULTATION FEE 7. ►J PLAN CHECKINU t•tI: 8. REAL ESTATE REQUEST: Water Well Inspection 11 Sample❑ Title Company Sewage System System Inspection ❑ Address ---_. - Tele. No. Escrow No. -- ------ Seller - _- Seller Address _ __- Telephone No. Seller Agent Name - Service Request For Date ------ -- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, an¢ rules and regu�tions of,the San Joaquin Local Heath District APPLICANT'S SIGNATURE X _- 3 ` Date kTitle .11 FOR DEPARTMENT USE ONLY 17"1 -- 1-1 ❑eru 1-1 la—ary 1 A Received By January 31 ❑ July 1 & Received By July 31 rcc REMIT BASE EXPLANATION BILLING DATE REMITTANCE DATE $ REMITTED AMOUNT DUE CHECKED AMOUNT FEE 510 r LESS f J l PRORATION PLUS PENALTY_... ----_--- _ OTHER OTHER --.------------------- Received by ----- - _ - Date Receipt No. Permit No Issuance Date Mailed Delivered APPLICANT -RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE., P.O. Boa 2009 STOCKTON. CA 952011