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Applications WIII Be Pro ed When Submitted Properly Completed. Be Su, Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED,GIVE <br /> ARPLICANT'S AND/OR FOOD ESTABLISHMENTS.MOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> AcENSE AND/OR POULTRY RANCHES AND KENNELS Regal. No. <br /> 3TRATION MISCELLANEOUS SERVICES <br /> I. .dER QOIOr <br /> (Application Date 0 Business/Name To Appear O Permit <br /> MType Permit/Service Requeste _ <br /> Ap licant Name �N G(AJ �ddress D 0 <br /> Business Telepho e No. '— 5 C '(er ency Telephone No. <br /> 5 7 <br /> <Property Location/ dres T <br /> i Property Owner IL W GlJ Address <br /> &yrLOperator's Name Address <br /> 1. FOOD ESTABLISHMENTS Total 'Iding 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 ❑ WATER SAMPLE(Bacterial) ❑ CHEMI AL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ W TER HAULER <br /> NO. OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH ❑.SWIMMING POOL ❑ SPA ❑ WADING OOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> r :ENNEL/Runways /Animal Population No. o.of Confining Cages <br /> Sewage Disposal Method <br /> SoliVWa Disposal MethodWatly Source Animal Waste D oa7SanJoaquin <br /> 6. SULTATK)N FEE ' f <br /> A, 42,51C <br /> 7. ❑ .PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ Sample[] Title Company <br /> Sewage System Inspection ❑ Address <br /> Escrow No. <br /> Seller Seller Address <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 doCountyordinances, state laws, and rules and regulations of the San Joaquin Local Health DAPPLICANT'S SIGNATURE X Title <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 July 1 A Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATION 1}7_90 DATE REMITTED AMOUNT E CHECKED <br /> Cn ` 1 AMOUNT <br /> FEE JP l ✓� G / <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER DAYS F12 J `- ;.PrLf TO PAOT^Ur <br /> +C. <br /> OTHER <br /> Received by Date Receipt No Permit No. Issuance Dale Malled Deli+mret <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.009 2002 STOCKTON.CA 11162011 <br />