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Applications Will Be Prod When Submitted Properly Completed. Be SureTo Sign The Application <br /> APPLICATION <br /> RONMENTAL HEALTH PERMIT/SERVI <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 /> BF30KER AND/OR REAL ESTATE INSPECTIONS Lic. No. ----- - -- <br /> irENSE ANDrOR POULTRY RANCHES AND KENNELS <br /> iTRATION MISCELLANEOUS SERVICES Regist. No. <br /> I. r3ER - _ Color <br /> Application Date 1-I— �'l Business/Name To Appear On Permit <br /> Type Permit/Service Requested:. _— ---- ,I i) <br /> q Applicant Name _ -� 7 Y`,Tt�yl"S -.-- — Address �.-L a-C_ `C 1 Ver" low 0) <br /> _ Business Telephone No.- - - Emergency Telephone No. <br /> IL Property Location/Address _� div {' tLI 4—t (L 4-4- <br /> Property <br /> -"Property Owner _E- t=C4t7-- - _ Address - <br /> LOperator'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 <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 /> 5. 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 /> Water Supply Source Animal Waste Disposal Method _ <br /> 6, ❑ CONSULTATION FEE -� ( }E �- 1 LI J I.f Ln �U l j LSU U t t t S <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 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE g REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br />' FEE <br /> LESS <br /> PRORATION ll V r <br /> PLUS <br /> PENALTY �] 1 _ <br /> OTHER f �G �C V h2— <br /> QTHER <br /> Received by Date Receipt No Permit No. Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: IRONMENTAL HEALTH PERMITlSE11VICES 1601 IELTON AVE.,P.O.Box 2DD9 STOCKTON,CA 95201 <br />