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Applications Will Be Processed When Submitted Properly Completed. 8To Sign The Application. <br /> APPLICATION <br /> ENGINEER'S AND/OA VIRONMENTAL HEALTH PERMIT/SERVICES <br /> APPLICANT'S AND/OR F000 ESTABLISHMENTS,HOUSING IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONS <br /> .Ir.ENSE AND/OR POULTRY RANCHES AND KENNELS Lic. No. <br /> I, .6ER3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> p Color <br /> [Application Date �: s•ness/N To Appear O} ermit'_ <br /> FType Permit/Sery q ested <br /> L <br /> — — -- <br /> vApplicant Name Address <br /> d siness Aelephone N Emergency Telephone No. <br /> IK <br /> Property Location/A dress <br /> aProperty 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. oI ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees _ <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING ENT <br /> qqP�A YWf <br /> ❑ HOTEL/MOTEL/No. of Units _ ❑ CERTIFICATE OF OCCUP7 '- <br /> ❑ MOBILE HOME PARK/No. of Spaces _ <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL JUN 7 19ea <br /> El PUBLIC WATER SYSTEM C3 SURFACE WATER SUPPLY ❑ WATER HAULER ! UU <br /> NO. OF PUBLIC SERVED (Connections) _ ENVIRONME <br /> 4. RECREATIONAL HEALTH ElSWIMMING POOL 1:1SPA 1:1WADING POOL 11NATURAL BAIP [� NTA1 HEALTH5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No, of Birds W <br /> ES <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 <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ Sample❑ Title Company <br /> P Y --. <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 hav repared this application and t the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, ules and regulatio of the n J aquin ocal ealthr District, t <br /> 1PPLICANT'S SIGNATURE X Title 5�=� <br /> Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 E Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> T DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE pX1�csart *! AMOUNT <br /> LESS <br /> PRORATION <br /> 'LUS <br /> 'ENALTY <br /> THER <br /> 'HER <br /> V7 I-roH <br /> ivetl by Date Recei Permit No Issuance <br /> 7LICANT—RETURN ALL COPIES TO: ENVIRONM HEALTH PERMIT/SEflY10E5 1601 E.HAZELT1 A E.,P.O. o'xe2009 STOCKTON,CA 95201 <br />