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Applications Will Be P�sed When Submitted Properly Completed. Belo Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> IF VEHICLE INVOLVED,GIVE <br /> ENGINEER'S AND/OR FOOD ESTABLISHMENTS.HOUSINGMake <br /> —.T - <br /> APPLICANT'S AND/OR - -- <br /> CONTRACTOR AND/OR PUBLICESTATE ATE I WATCH SAMPLING <br /> KCAL EINSPECTIONS LIC. N0. --- <br /> BROKER AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> irFNSE AND/OR MISCELLANEOUS SERYICILS <br /> .iTRATION • _5.l} '�-� l Color <br /> I. -. —. <br /> f Application Date1-- [�-J-�- - .- Busings/Name To Appear On Permit - — <br /> Type Permit/Service Requested: - <br /> a Ap �C,. t�\v,17 1 `gip C15— -- - Address <br /> 1icaM Name - Cir _. <br /> r? p �3 ` 6usl ess Telephone Na. - � - - 'Emergency Telephone No. <br /> LTC\ + `�5--- _Q <br /> ,,Properly Location/Address <br /> Property Owner cvr` �°=T- --- — -- —- .. Address -- — —. <br /> 1 <br /> Address — <br /> Operator's Name ----�- <br /> T. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> 13 RESTAURANT 1:1 FOOD MARKET RETAIL <br /> El MARKET WHOLESALE MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT 13 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 —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 _—_ <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> 13 PUBLIC WATER SYSTEM 11 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 /> /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 /> g. ❑ CONSULTATION FEE - -- --� --- <br /> i. ❑ PLAN CHECKING FEE <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection Sample❑ Title Company _ <br /> Sewage System Inspection ❑ Address ____——_-._- -- <br /> 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 a Received By January 31 ❑ July 1 S Received By July 31 <br /> -- ---- — ___ REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> OATS DATE REMITTED AMOUNT— <br /> FEE <br /> MOUNT— <br /> LESS ---- — -- - L� <br /> PRORATION <br /> PLUS <br /> PENALTY �..-- ---- - <br /> OTHER <br /> OTHER <br /> Received by f Date <br /> *epl N. �Pe+mil No I• a Date Mfliled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br /> 1801 E.HA2ELTON AVE.,P.O.ea■1004 570CKTON,CA 45201 <br />