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Applications Will Be Pro d When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> E ©NMENTAL HEALTH PERMIT/SERVI IF VEHICLE INVOLVED, GIVE <br /> ENGINEER'S ANDiOR FOOD ESTABLISHMENTS.HOUSING Make - - - - - - <br /> APPLICANT`S AND/OR 4 . PUBLIC POOLS,WATER SAMPLING Lic No. - --- - -- -- - <br /> CONTRACTOR AND�OR REAL ESTATE INSPECTIONS <br /> BROKER ANDrOR POULTRY RANCHES AND KENNELS Reglst. No. - <br /> ,r1=NSE ANDfOR MISCELLANEOUS SERVICES . Color --- - - - <br /> 3TRATION " <br /> 3ER <br /> Application Date .--- _ Business/Name To Appear On Permit - <br /> Type permit/Service Requested:- --- --- - _ <br /> = Address <br /> r <br /> Applicant Name --- - `,, -_ Emergency Telephone No.di <br /> - - - <br /> i;iy _��, Business Telephone No --- - - <br /> 4 Property Location/Address-. Address - - - - - - <br /> 4 Property Owner . 'l� - - - - - - - - - - - <br /> Address -- <br /> 1 Operator's Name Restaurant, Maximum Seating Capacity <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage 13MEAT MARKET <br /> E] RESTAURANT 11 FOOD MARKET RETAIL 13 FOOD MARKET EPLA WHOLESALE 13 BAKERY <br /> [I COMMISSARY 13 ICE PLANT <br /> ❑ FOOD PROCESSING PLANT ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ ROADSIDE FOOD STAND 11 LIQUOR STORE 13 FOOD VENDOR <br /> E-] CONFECTIONARYSTORE ❑ FOOD SALVAGER C1 FOOD DEMONSTRATION <br /> ❑ MOBILE FOOD PREP. UNIT El VENDING VEHICLE <br /> ❑ VENDING MACHINES/No. of <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees -- - <br /> ALL APPLICANTS, Total Employees Including Operators-._ -- - - <br /> 2. HOUSING ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ HOTEL/MOTEL/No of Units - - - - <br /> ❑ MOBILE HOME PARK/No. of Spaces - - 13 CHEMICAL <br /> 3. WATER QUALITY C1 WATER SAMPLE (Bacteria;) <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) - - - --� SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 4. RECREATIONAL HEALTH [I SWIMMING POOL <br /> 5. VECTOR CONTROL POULTRY FARM/Maximum No. of Birds - - -- -- -- - - - <br /> No. of Confining Cages_ <br /> r '.ENNEL/Runways - - _ /Animal Population No. - - - - - - <br /> Sewage Disposal Method - - -- - - -- - - - - - - <br /> Solid Waste Disposal Method .- __ - Animal Waste Disposal Method - — — - - <br /> Water Supply Source <br /> 6. ❑ CONSULTATION 'FEE - <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE -- - - - - - <br /> _ - - - - - -- <br /> REQUEST: Water Welllnspection❑ Sample[] Title Company Tele. <br /> _ No <br /> Sewage System Inspection ❑ Address — <br /> Escrow <br /> ddress _ -Escrow No - - - - --_ - - <br /> Seller Address - - --- - — <br /> Seller <br /> Telephone No. - - - - - - Seller Agent Name <br /> Service Request For Date - - - -- - - - - - - -- <br /> It be done in accordance with San Joaquin County <br /> I hereby certify that I have prepared this application and that the work wi <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X --- - - --- - - <br /> - - - Title Date —FOR DEPARTMENT USE ONLY <br /> Fee Is Due ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedFlyJuly 31 <br /> MIT <br /> BILLING REMITTANCE 5 AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT-- <br /> - — <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER — - —1 — <br /> -- fleceipt Nu. Permit Na Issuance Date Mailed Delivered — <br /> Rer.ecved by Date <br /> leolLMMAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95291 <br /> APPLICANT-RETURN ALL COPIES TO: IRONMENTAL HEALTH PERMITISERVICES <br />