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Applications Will Be P•^ -%sed When Submitted Properly Completed. Be Sur-To Sign The Application. <br /> APPLICATION �J <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR F000 ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS, WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS LIC. No. <br /> IrtENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 9TRATION MISCELLANEOUS SERVICES Regist. NO. <br /> I. .aER �Color <br /> I <br /> r Application Date "f `-1 Q Bu 'n ss/Name To Appear On Permit �0.�T1rG t_S.LLJ <br /> aType Permit/Ser 'ce Requested: <br /> =A licant Name vim- A ress��� �s rG°nLim <br /> Business Telephones N `i(b �^l�'1�1 N?_�-1 Emergency Telep one o��� 3Z <br /> 9P rtI t' /Add w ii.z% F­y-lIZ1CX%'4 <br /> Property Owner 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 <br /> ❑ MOBILE HOME PARK/No.of Spaces Nj <br /> 3. WATER QUALITY ❑ WATER SAMPLE(Bacterial) P A3 #40 <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SL*Fj�iGF- WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH 1111 �R SWIMMING POOL INA t POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> r '.ENNEL/Runways /Animal PopulationENpp.. .+�LMEI`�TR `C c No. of Confining Cages <br /> Sewage Disposal Method V��IT SE - <br /> Solid Waste Disposal Method <br /> Water Supply Source ._ Animal Waste Disposal Method <br /> 6. �❑3CONSULTATION FEE <br /> T. Fig PLAN CHECKING FEE bA-90Ck.-A ` C'i�b�1n Pt/I Sti n e <br /> B. 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 /> APPLICANTS 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 S REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received Cy Date \ /sot No. Permit No. Issu fits Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1901 E.HAI ON AVE..P.O.Box 20011 STOCKTON.CA 95201 <br />