Laserfiche WebLink
Applications Will Be Pre ssed When Submitted Properly Completed. Be Sur-To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR <br /> APPLICANT'S AND/OR F000 ESTABLISHMENTS. HOUSING IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR PUBLIC POOLS, WATER SAMPLING Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONS L.C. No. <br /> IrF_NSE AND/OR POULTRY RANCHES AND KENNELS <br /> STRATION MISCELLANEOUS SERVICES Regist. No. <br /> I. AER _ Color <br /> [Application Date Business/Name To Appear On Permit <br /> Type Permit/Service eq ested: !�!'!M =� 1.SL110C�_r 'dY1- <br /> ApplicantName ` IM IIr10IPf- 0112 Address 3 f� G <br /> O <br /> u By�lsmesa Telephone No. Emergency Telephone No. <br /> i Property Location/Address <br /> I Property Owner I�13 TS 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/ e�C MFyI <br /> 11 MOBILE HOME PARK/No. of Spaces - / <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL vEC <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> FIV,O <br /> NO. OF PUBLIC SERVED (Connections) J„ <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHIfjPQ�f� <br /> �5. VENNELRuECTOR CONTROL ❑ POULTRY mal Population No.aximum No. of Birds No. of Confining Cages <br /> Co <br /> �CfcAtTN <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Su y Source _ Animal Waste Disposal Method <br /> 6. CONSULTATION FEE �+ <br /> T. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well inspection 13 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 ❑ julf 1 8 Riwei d By July 31 <br /> EMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DU C CKED <br /> �/ OUNT_ <br /> FEE 4 AW 7 <br /> LESS .7� <br /> PRORATION <br /> PLUS <br /> PENALTY PFNAI TIESC <br /> OTHER DAYS FROM BILLING D TE. <br /> OTHER <br /> 33r <br /> Received by Date ceipt No Freood Nosauarice Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE.,P.O.90.MW STOCKTON.CA 115201 <br />