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Applications Will B s )Cessed When Submitted Properly Completed. 6 .Ire To Sign The Application. <br /> APPLICATION <br /> ENGINEER'S AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> APPLICANT'S AND/OR <br /> CONTRACTOR AND/OR F000 ESTABLISHMENTS.HOUSING IF VEHICLE INVOLVED, GIVE <br /> BROKER ANO/OR PUBLIC POOLS.WATER SAMPLING Make <br /> IrENSE AND/OR REAL ESTATE INSPECTIONS - <br /> 3TRATION POULTRY RANCHES AND KENNELS LIC. NO. <br /> I. AER MISCELLANEOUS SERVICES Reg ist. No. _ <br /> / <br /> [Application Date 9O—�� � Business/Name To Appear On Permit Color <br /> ✓ T <br /> i Type Permit/Service Requested: <br /> Applicant Name <br /> M Address <br /> M Bus, ass Telephone No. O�Emergency Telephone No <br /> `Property Location/Atldress ;?Z /fes TejQI <br /> iProperty Owner <br /> LOperatois Name -- <br /> !lJ _ Address Address(J OL'y3fi�y <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 <br /> 13ROADSIDE FOOD STAND ElLIQUOR STORE 11 BAR <br /> ❑ BAKERY / <br /> ❑ CONFECTIONARY STORE11 ITINERANT❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR RESTAURANT 6 <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 DUALITY ❑ WATER 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 Sup y Source -- Animal Waste Disposal Method <br /> 6. ZCONSULTATION FEE <br /> 7. ❑ .PLAN 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 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 /> 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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE / <br /> LESS //-- <br /> PRORATION <br /> PLUS <br /> PENALTY 9- <br /> OTHER <br /> OTHER <br /> Received by pate eceipt No Permit No. Issuance Data Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1901 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON.CA 95201 <br />