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Applications Will Be Pr�sed When Su APPLProperly ICATION completed. Be *d,Sign The Application. <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES IF VEHICLE INVOLVED, GIVE <br /> ---------- <br /> ENciINL!R' Make <br /> AND/OH E000 ESTABLISHMENTS.ROUSING — <br /> APPLICANT'S AND/OR PUBLIC POOLS.WATER SAMPLING Lic. No. ------ <br /> CONTRACTOR AND/OR REAL ESTATE INSPECTIONS <br /> BROKER AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> IrFNSE AND/OR MISCELLANEOUS SERVICES Color — — <br /> iTRATION <br /> I. ,BER <br /> r Application Date O—� Business/Name To Appear On Permit <br /> tA <br /> .Type Permit/Service Reques ed: u <br /> .. r _ /T . r , K4 Gr^+gAddress <br /> a Applicant Name °__.�1p "_EYP"/ Emergency Telephone No. <br /> u Buslrr1�,ss Tele hone No. <br /> %Property Location/Plress _ _ Address -- <br /> `Property Owner � '� 'S <br /> Address -- <br /> �Operator's Name — Restaurant,Maximum Seating Capacity <br /> Total Building Sq. Footage ❑ MEAT MARKET <br /> 1. FOOD <br /> ESTABLISHMENTS <br /> RETAIL ❑ FOOD MARKET WHOLESALE <br /> 13 RESTAURRANTANT ISHM❑ FOOD MA ❑ <br /> 13 ICE PLANT BAKERY <br /> ❑ FOOD PROCESSING PLANT [I COMMISSARY ❑ ITINERANT RESTAURANT <br /> ❑ LIQUOR STORE ❑ BAR 11 FOOD VENDOR <br /> 11 ROADSIDE FOOD STAND ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION <br /> ❑ CONFECTIONARY STORE ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ VENDING MACHINES/No. of - <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees <br /> 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 ❑ CHEMICAL <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ WATER HAULER <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY <br /> NO. OF PUBLIC SERVED (Connections) ❑ SPA El WADING POOL LJ NATURAL BATHING PLACE <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL <br /> 5. VECTOR CONTROL ❑ POULTRY FARof Birds <br /> FARM/Maximum No. — No. of Confining Cages <br /> r :ENNEL/RVnways --- /Animal Population No. <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method Animal Waste Disposal Method <br /> water Supply Source <br /> 6. CONSULTATION FEE <br /> 7. ❑ .PLAN CHECKING FEE <br /> 8. REAL ESTATE _ <br /> REQUEST: Water Well InspeInspection[] Sample Address Title Company Tele. No. <br /> Sewage System Inspection <br /> Escrow No. -- <br /> --- Seller Address <br /> Seller <br /> Telephone No. Seller Agent Name <br /> Service Request For Date <br /> ation and that the work will al done in accordance with San Joaquin County <br /> I hereby certify that I have prepared this applicof the San Joaquin Local Heal <br /> ordinances, state laws, a rules and r gulations Health District. <br /> Title Date <br /> APPLIC IGNATU _ <br /> FOR DEPARTMENT USE ONLY <br /> ❑ ER SITE ❑ EACH ❑ January 1 &Recelve0 By January 31 El July 1 &ReceiveddEBAly July 31 <br /> Fee IS Due: ❑ ANNUALLY [3 PER NIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED'+ AMOUNT <br /> FEE -3 �� Ov <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> .HAZEL¢Date Mailed <br /> Reivetl by <br /> ecDate Receipt No. Permit No. Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTOKTON.CA 95201 <br />