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v Applications Will Be F� ,sad hen Submltteo Property Completed. Be . to Sign The Application. <br /> #000 �/ 'WAPPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGI EER'S AND/OR <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> IrF_NSE AND/OR POULTRY RANCHES AND KENNELS <br /> STRATION MISCELLANEOUS SERVICES RegiSt. NO. _. <br /> i. .dER Color <br /> f Application Date r Business/Name To Appear On Permit - _ �7- <br /> Type <br /> Type Permit/Service Requested:-- <br /> Applicant <br /> equested Applicant Name Address <br /> 44 Business Telephone No Emerge <br /> Property Location/Address <br /> Property Owner Address <br /> L Operators Name �` __. - /��:ice. /YfNr Address i <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Beall��`Q` apaGlty .... <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEATIAAR I ET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDII 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) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO, OF PUBLIC SERVED (Connections) <br /> A. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> F .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 /> S. LYCONSULTATION FEE <br /> T. ❑ PLAN CHECKING FEE _ <br /> S. 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 Dae: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 A Receives By July 31 <br /> REMIT <br /> BILLING REMITTANCE 6 <br /> BASE E%PLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT_ <br /> FEEpf "C'LESS <br /> cv <br /> PRORATION �L „L /(fJ-6:911 r , <br /> PLUS <br /> PENALTY f y',irj <br /> OTHER PENALTIES WI L BE APPLIE TO PAST DUE ACCOUNTS 3f I <br /> OTHER TAYS FROM ILLING DA <br /> 7 t�/ <br /> Recewea Dy Dow Receipt No. Permit No IseWrlee Data Maiw Dshverea <br /> APPLICANT—RETURN ALL COPRA TO: ENV"KMWWAL HEALTH PERMIT/aeRVICES 1Net E.HAZELTON AVE..PO.sea 7DM 11TOCKTON.CA"set <br />