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Applications Will Be P sed When Submitted Properly Completed. Be S�To Sign The Application. <br /> APPLICATION <br /> ENGINEER'S AN6iOR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> APPLICANTS ANDCR FOOD ESTABLISHMENTS,HOUSING IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/CR PUBLIC POOLS.WATER SAMPLING Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Li No <br /> ITF_NSE AND/OR POULTRY RANCHES AND KENNELS <br /> iTRATION MISCELLANEOUS SERVICES Regist. No. <br /> i, t3ER Color <br /> d Application Date _3 _cep Business/Name To Appear On Permit <br /> (aType Permit/Service Requested: <br /> � <br /> Applicant Name �( Facr�I17N /i '"m Address 46 <d it IV tom <br /> �r—, s <br /> a Business Telephone No, Emergency Telephone No. <br /> a Property Location/Address �• � <br /> I Property Owner S,�2t car �(Ls4/r£4!7500 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 ds���� <br /> ❑ HOTEL/MOTEL/No. of Units ❑ C _*,V;g7OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces 1 � <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL �'�'� N© <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WWR HAU�i� / �,�AV <br /> NO. OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADI4 NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds & <br /> r :ENNEL/Runways ____ /Animal Population No. _ No. of ttnfining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source __ Animal Waste Disposal Method <br /> 8. ❑ CONSULTATION FEE <br /> 7.,�AN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <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 pre red this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r e and gu tions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receive By January 31 ` July 1 &Received By July 31 <br /> REMI <br /> REMITTANCE T <br /> BASE EXPLANATION BILLING R <br /> DATE DATE RE ITTED AMOUNDUE CHECKED <br /> p AMOUNT <br /> FEE <br /> LESS « <br /> PRORATION <br /> PLUS <br /> PENALTY t <br /> OTHER <br /> OTHER <br /> Received by Date eipt No. Permit No Iss Date Ma— <br /> iled <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />