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° Applications Wfll Be F�:ssed When Submitted Properly Completed. Be . To Sign The Application. I_ / <br /> APPLICATION <br /> i988 ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEERS ANoI/_P J'Jtt11 IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR <br /> FOOD ESTABLISHMENTS.HOUSING Make <br /> CONTRACTOR AND/CR PUBLIC POOLS.WATER SAMPLING - — <br /> ^ROKER AND/OR - REAL ESTATE INSPECTIONS Lie. No. _ <br /> ENSE AA((JJIq�(.QQRI(LI[.Ij�I t=;=L:.Gtr `a r' `� POULTRY RANCHES AND KENNELS <br /> eTRAYIdN¢¢/, IiAI`�tN 00 CALIF MISCELLANEOUS SERVICES Reglst. <br /> Color <br /> (Application Date uBuSiness/Namppear n Permit __- r _ /r <br /> FII Type Permit/Service.�R�e�qu�pe t/ed: � CAJ° ,�_�L <br /> Applicant Name —J!_ja.(]�4t] .Q� Add -2;Fii <br /> u <br /> d 51fZ Business Tglephone�lNo�.--c{� . Emergency Telephone No. <br /> o art n/Address �1E.��I/t'e_ 1 V1G14�! <br /> Property Owner + _ >�g� _ __ Address <br /> -L 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 PAYMENT <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY RECEIVED <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL OCT9oO <br /> ❑ PUBLIC 11 1 <br /> WATER SYSTEM ❑ SURFACE WATER SUPPLY WATER HAULER U 88 <br /> NO. OF PUBLIC SERVED (Connections) �p <br /> 4. RECREATIONAL HEALTH 11SWIMMING POOL ❑ SPA 11WADING POOL 11NATURAL BATHING PNAC�ONMENTAL ypgLTy <br /> VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds Y�RMIT/SEQVIC€S <br /> 111✓ :ENNEURunways _ /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source _. Ani ste Disposal Method, <br /> 6. Ar 4ONSULTATION FEE <br /> 71, <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 /> REMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> r (� AMOUNT_ <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> ! PENALTY <br /> OTHER LIIES WILL BE APPLIED TO PACT DUE ACC UNTS 0 <br /> CNATr <br /> OTHER71, <br /> R ed by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.NAZELTON AVE..P.O.Boa 2009 9TOCKTON,CA 95201 <br />