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Applications Will Be Pr*ed When Submitted Properly Completed. Be So Sign The Application. <br /> APPLICATION <br /> ENGINEERS AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> APPLICANT'S AND/OR <br /> CONTRACTOR AND/OR FOOD ESTABLISHMENTS.HOUSING IF VEHICLE INVOLVED, GIVE <br /> BROKER AND/OR PUBLIC POOLS,WATER SAMPLING • <br /> .InE 3TRAND/OR REAL ESTATE INSPECTIONS pgst� <br /> IViTRATION POULTRY RANCHES ANO KENNELS YNHE_I. .BER MISCELLANEOUS SERVICES <br /> pq Color <br /> [Application Date O / Business/Name To Appear On Permit <br /> FType Permit/Service Re <br /> quested:—� <br /> z<APplicantName S �i�14��" ✓ f C- <br /> �� l�'�-� <br /> Ad rens_ Y_ / Lu �ir fr�/ �� <br /> Buess Telephone No. <br /> 'a Property Location/Address__- $ pJl' �p Emergency Telephone No. <br /> aProperty Owner <br /> -L Operator's Name — Address <br /> 1. FOOD ESTABLISHMENTSAddress <br /> 1:1Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT <br /> OD <br /> ❑ FOOD PROCESSING PLANT11 COMMISSARY ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ ROADSIDE FOOD STAND 1:1 LIQUOR STORE ❑❑ B RPLANT ❑ BAKERY <br /> 11CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION 0 <br /> FOOD VENDOR <br /> CI FOOD <br /> RESTAURANT <br /> El VENDING MALINESN. of 1:1 MOBILE FOOD PREP. UNIT El VENDING VEHICLE <br /> FOOD CROP HAA RVESTITING/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 /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> r :ENNEL/Runways /Animal Population No. <br /> Sewage Disposal Method No.of Confining Cages <br /> Solid Waste Disposal Method <br /> Water SupISTY Source _ <br /> 6. 0 CONSULTATION FEE Animal Waste Dsal Method <br /> 7. ❑ PLAN CHECKING FEE +M-7,0 " Q, h <br /> 8. 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, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January1 a Received By Januar 31 <br /> Y ❑ July 1 A Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNTDUE CHECKED <br /> FEE 3 %�• � S AMOUNT <br /> LESS Z �7 <br /> O, 9O ,� � �_ <br /> PRORATION <br /> PLUS /� I' q <br /> PENALTY ST D E ACCOU 30 <br /> OTHER DAYS FRO BILLING D E. _- <br /> OTHER — - <br /> Received by DaleeiPl __ <br /> No. Permit No —— — --- —__ _ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES sc�Dale Mailed Delivere0 <br /> 1601 E.HAZELTON AVE.,P.O.Bm 2009 STOCKTON,CA 95201 <br />