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' APPlications Will Be Prod& When Submitted Properly Completed. Be Sur <br /> APPLICATION oign The Application. <br /> ENGINEER'S AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES CALTR84 <br /> APPLICANT'S AND/OR <br /> CONTRACTOR AND/OR FOOD ESTABLISHMENTS. HOUSING IF VEHICLE INVOLVED, GIVE <br /> BROKER AND/OR PUBLIC POOLS. WATER SAMPLING Make <br /> IPENSE AND/OR REAL ESTATE INSPECTIONS <br /> 3TRATION POULTRY RANCHES AND KENNELS Lic. No. <br /> I. .eER MISCELLANEOUS SERVICES Regist. No. <br /> p Color <br /> f Application Date�� O Business/Name To <br /> W Type Permit/Service Requested:___ [ Appear On Permit <br /> Applicant Name _e <br /> u — Bu ass Telephone No._ <br /> `'Property Location/Address �h� Emergency Telephone No. <br /> iProperty Owner f ----- <br /> (Operator's Name — Address <br /> 1. FOOD ESTABLISHMENTSAddress <br /> 11RESTAURANT 11Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> OD MARKET RETAIL <br /> CIFOOD PROCESSING PLANT11COMM COMMISSARY ❑ FOOD MARKET WHOLESALE 13 MEAT MARKET <br /> El ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑❑ ICER <br /> RPLANT 11 BAKERY <br /> ❑ CONFECTIONARY STORE 11 FOOD SALVAGER El FOOD FOOD 13 <br /> ITINERANT RESTAURANT <br /> ❑ VENDING MACHINES/No. of ❑ FOOD VENDOR <br /> ❑ MOBILE FOOD PREP. UNIT El 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 b�1 <br /> ❑ MOBILE HOME PARK/No. of Spaces ❑ CERTIFICATE OF(SE+a�y7��, <br /> 3. WATER QUALITY ❑ F V•�T <br /> WATER SAMPLE (Bacterial) ❑ CHEMICAL r'1 lei !D <br /> ❑ PUBLIC WATER SYSTEM ❑ n 9 <br /> NO. OF PUBLIC SERVED (Connections)SURFACE WATER SUPPLY ❑ WATER HAULER �R Q <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ P sAN�oA 5 1^980 <br /> 5. VECTOR CONTROL ❑ SPA ❑ WADING POOL (/ �''f'Nn,, <br /> r POULTRY FARM/Maximum No. of Birds �w SAA IN CE^ <br /> :ENNEL/Runways _ /Animal Population No. HEAL , <br /> a.;y <br /> fj ; <br /> Sewage Disposal Method�— �— No.of Confining Caged I`SInn/ <br /> Solid Waste Disposal Method <br /> Water S ly Source <br /> 6. CONSULTATION FEE _a5=e-r� Cao Animal Waste Di posal Method <br /> 7. ❑ .PLAN CHECKING FEE J /� 1 h 4 I / <br /> y <br /> a. REAL ESTATE - <br /> REQUEST: Water Well Inspection❑ Sample[] Title Company <br /> Sewage System Inspection ❑ Address <br /> Escrow No. _ -- Tele. 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, <br /> (a/rt"+ rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X v_�� I�"'y Y1. <br /> Title O/i- Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH <br /> - 11 January 1 8 Received By January 31 ❑ July 1 8 Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> //--�� � DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE 3 - ( . ,�j /VE/J, AMOUNT_ <br /> LESS $ <br /> PRORATION <br /> PLUS L7TES W► <br /> PENALTY L BEA <br /> OTHER <br /> — SAFE 'Pt — <br /> OTHER <br /> Rucerve1l UY Dale ff7� __ � , • — <br /> ceipl No Purmrl No. Issuar a Date <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES P.C.Box 2 STOCK <br /> O <br /> 1601 E.HAZELTON AVE., .Boy aNK STOCKTON.CA 95301 <br />