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Applications Will Be Pa seed When Submitted Properly Completed. Be To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S.CND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make <br /> CON4RACTOR AND/OR PUBLIC POOLS.WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Li C. No. <br /> .IrENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. _ <br /> I. AER Color <br /> [Application Date Business/Name To App11 ear On Permit <br /> HType Permit/Service IRequesteyl: <br /> `Applicant Name '(" Address <br /> U <br /> A.0 Business Telephone No" Emergency Telephone No. <br /> 'a Property Location/Address <br /> Property Owner Address {� 0 / -1Ln. �1 1 <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 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 /> r :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 /> 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 Fhe44-have-prepafed-this-application-en9 that the work will be done in accordance with San Joaquin County <br /> ordinances, st laws, and rules and regulations of the San Joaquin Local Health District.District. _' y <br /> APPLICANT'S SIGNATURE `\ Title <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January.34 July 1 6 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE F,XPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> (p AMOUNT <br /> 1 — <br /> FEE <br /> LESS / <br /> PRORATION _- <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1 <br /> Received by Dale ,I N. Perms No Issu ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVI�ENTAL HEALTH PERMIT/SERVICES 1601 E.HA. N AVE.,P.O.Boy]009 STOCKTON,CA 95201 - <br />