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4 <br />• r <br />Applications Will Be f ssed When Submitted Properly Completed. Be To Sign The Application. <br />r <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />REMIT <br />ENGINEER'S AND'OR <br />BASE <br />IF VEHICLE INVOLVED, GIVE <br />APPLICANT'S AND/OR <br />FOOD ESTABLISHMENTS. HOUSING <br />Make <br />CONTRACTOR AND/OR <br />PUBLIC POOLS, WATER SAMPLING <br />— <br />BROKER AND/OR <br />REAL ESTATE INSPECTIONS <br />Lic. No. <br />'ENSE AND/OR <br />POULTRY RANCHES AND KENNELS <br />Regist. No..___ <br />3TRATION <br />MISCELLANEOUS SERVICES <br />aER — <br />—�� <br />Color .--- — — — - - <br />Application Date Business/Name To Appear On Permit _ <br />_ Tv o Pnrmit/Cnrvirn Pa—actcrl <br />i Applicant Name ----—------- —.. Address _—_ ._-_----- <br />U <br />Business Telephone No. __—_____ Emergency Telephone No. <br />4 -- <br />Property Location/Address <br />/ <br /><Property Owner 1I,/ A _ —_ - Address —:- <br />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 ❑ 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 C3WATER 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 />S. VECTOR CONTROL ❑ 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 Supply Source _ _ Animal Waste Disposal Method <br />A ❑ CANSLILTATIAN FFF <br />7. ❑ PLAN CHECKING FEE <br />8. REAL ESTATE <br />REQUEST: Water Well Inspection❑ Sample❑ Title Company <br />Sewage System Inspection <br />Escrow No. - <br />Seller <br />Telephone No. <br />Service Request For Date <br />Address <br />Seller Address <br />Seller Agent Name <br />Tele. No. <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 <br />Title <br />Date <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 n .luly 1 A Rar.-Pr1 Rv I dv 91 <br />Received by Date ipt No Permit No Iaat Data Mailed Delivered <br />APPLICANT—RETURN ALL COPIES TO: ENVI,._.,MENTAL HEALTH PERMIT/SERVICES 445 N. San Joaquin St. P.O. Box 2009 STOCKTON, CA 95201 <br />REMIT <br />BASE <br />EXPLANATION <br />BILLING <br />REMITTANCE <br />f <br />AMOUNT DUE <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEE <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />Received by Date ipt No Permit No Iaat Data Mailed Delivered <br />APPLICANT—RETURN ALL COPIES TO: ENVI,._.,MENTAL HEALTH PERMIT/SERVICES 445 N. San Joaquin St. P.O. Box 2009 STOCKTON, CA 95201 <br />