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Applications Will Be Psed When Submitted Property Completed. Be S To Sign The Application. <br /> r �r aJ <br /> __t ids <br /> APPLICATION <br /> +•.'�' + . .. ENVIRONMENTAL HEALTH PERMIT/SERVICES IF VEHICLE INVOLVED, GIVE <br /> eNGINEER'S AND/OF F000 ESTABLISHMENTS.HOUSING Make — <br /> APPLICANT'S AND/OPk - _ PUBLIC POOLS.WATER SAMPLING L'Ic. NO. <br /> CONTRACTOR AND/OR REAL ESTATE INSPECTIONS <br /> BROKER AND/OR �--� POULTRY RANCHES AND KENNELS Reglst. NO. <br /> ir.ENSEAND/OR MISCELLANEOUS SERVICES Color <br /> 3TRATION <br /> I. ,BER <br /> Application Date�=2--� in <br /> Busess/Name To Appear On Permit <br /> f <br /> I,Type Permit/Service Requested: /? C <br /> Address <br /> ` <br /> Ap licant Name / Emergency Telephone No. <br /> O B sines Telephone o. <br /> J <br /> `Property-Location/Address Address _ <br /> iProperty Owner Address <br /> Operator's Name Restaurant, Maximum Seating Capacity <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage ❑ MEAT MARKET <br /> E3 RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE 11 BAKERY <br /> ❑ COMMISSARY 13 ICE PLANT <br /> ❑ FOOD PROCESSING PLANT ❑ BAR ❑ ITINERANT RESTAURANT <br /> C3 ROADSIDE <br /> FOOD SALROADSIDE FOOD STAND 11F O D S STOREVAGER 11 FOOD DEMONSTRATION IJ FOOD VENDOR <br /> ❑ CONFECTIONARY STORE 11 VENDING VEHICLE <br /> ❑ MOBILE FOOD PREP. UNIT <br /> ❑ VENDING MACHINES/No. of <br /> ❑ FOOD CROP HARVESTING/No. of FJ4Id Employees �— <br /> ALL APPLICANTS: Total Employees Including Operators_- <br /> 2. HOUSING ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ HOTEL/MOTEL/No. of Units —I—, T <br /> ❑ MOBILE HOME PARK/No. of Spaces ❑ CHEMICAL RECD IN] <br /> EDS <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ WATER HAULER <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY, cc�[{{�� 11 19B3 <br /> NO. OF PUBLIC SERVED (Connections) ❑ SPA ❑ WADING POOL ❑ NATURALWA 4 1113 PLACE <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL y„ MENTAL HEAuTH <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds No.of ConfiniN <br /> '1S.fwe" <br /> r '.ENNEL/Runways — /Animal Population No. VEW,I <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method Animal Waste Disposal MTod <br /> Water Supply Source <br /> 6, UD CONSULTATON FEE <br /> 7. .PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ Sample❑ Title Company <br /> Address Tele. No. <br /> Sewage System Inspection <br /> Escrow No. - <br /> Seller Address <br /> Seller <br /> Telephone No. Seller Agent Name _ <br /> Service Request For Date 1� <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 /> _ _ _ Title Date <br /> APPLICANT'S SIGNATURE X _. <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 B ReceiveRdEMIBY TuIy 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT_ <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> p o 10'l"7 b 52-5� <br /> Date Receipt No. <br /> Permit Na. Iss ce ate Mailed Delivered <br /> Received by 1601 E.HAZELTON AVE.,P.O.90-2009 STOCKTON.CA 9520 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />