Laserfiche WebLink
Applications Will Be Pseed When Submitted Properly Completed. Be to Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING Make — <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS LIC. NO. <br /> IrFNSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRAT lO 6' ^J MISCELLANEOUS SERVICES 1. <br /> N0. <br /> I. .BER _ — _.— Color _ <br /> Je-[Application Date a3 Business/Name To Ap�ea�r .One Permit <br /> m Type Permit/Service equesled: Anti -(c> I �7tt-S! ' — <br /> T% 2.vS Luv aliL„J <br /> Applicant Name ((JA-=+� »� »��s-tYu-a �L Address Lv`L S ` ILS J f4.acr S;cx.D� <br /> u -- Business Telephone No. Emergency Telephone No. <br /> aProperty Location/Address y ✓ <br /> iProperty Ownerr+'cc:- <br /> Address ��// 0✓9vci /J2 �7lx�-� L <br /> Operator's Name —1=>I; Seng 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 <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) <br /> 4. 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 /> Wa er SupplySource Animal Waste Disposal Method <br /> 6. CONSULTATION FEE 3S <br /> 7. ❑ .PLAN CHECKING FEE 6 <br /> 8. REAL ESTATE A <br /> REQUEST: Water Well Inspection 13 Sample❑ Title Company '9r <br /> Sewage System Inspection ❑ Address TgFANo. <br /> Escrow No. C- <br /> Seller Seller Address <br /> Telephone No._ Seller Agent Name <br /> Service Request For Date ,,c(���� <br /> I hereby certify that I have prepared this application and that the work will be done in aceQfidy 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 I9 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 a Received By July 31 <br /> BILLINGREMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE �✓S^ �1 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receipt a <br /> t NoIssuance Date Mailed Delivered <br /> J5 - <br /> veby titl <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1901 E.HAZELTON AVE.,P.O.Box aide STOCKTON,CA 95201 <br />