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Applications Wi11 Be Pod When Submitted Properly Completed. Be 0 Sign The Application. <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES VE <br />ENGINEER'S AND/OR <br />FOOD ESTABLISHMENTS, HOUSING <br />APPLICANT'S ANDrOR <br />PUBLIC POOLS, WATER SAMPLING <br />CONTRACTOR AND/OR <br />REAL ESTATE INSPECTIONS <br />BROKER ANDrOR <br />POULTRY RANCHES AND KENNELS <br />irENSE AND!OR <br />MISCELLANEOUS SERVICES <br />3TRA71ON <br />BILLING <br />BER <br />$ <br />IF VEHICLE INVOLVED, GI <br />Make - — - - <br />Lic, No. - <br />Regist. NO. — <br />Color <br />Appbication date Business/Name To Appear On Permit , t c r ` <br />c4✓iJ? 2 <br />Type Permit/Service Requested: <br />-.7 i . — Address <br />e Applicant Name r' ' F ' <br />U`� Business Telephone No. Emergency Telephone No. <br />IL Property Location/Address <br />aProperty Owner _ - .—. � �.4 ` - Address <br />L Operator's Name — — - <br />~ _ 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 />hl- APPLICANTS Total Employees Including Operators - — - <br />2. HOUSING <br />L7 HOTEL/MOTEL/Na. of Units - 11 CERTIFICATE OF OCCUPANCY <br />❑ MOBILE HOME PARK/No. of Spaces - <br />3. WATER OUALITY ❑ WATER SAMPLE (Bacterial) CHEMICAL <br />El PUBLIC WATER SYSTEM 1:1 SURFACE WATER SUPPLY WATER HAULER <br />NO. OF PUBLIC SERVED (Connections) _ NATURAL BATHING PLACE <br />4. RECREATIONAL HEALTH 11 SWIMMING POOL 1:1 SPA ❑ WADING POOL <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 i <br />Solid Waste Disposal Method <br />Water Supply Source Animal Waste Disposal Method <br />S. ❑ CONSULTATION FEE <br />7. ❑ PLAN CHECKING FEE <br />8. REAL ESTATE <br />REQUEST. Water Well Inspection 11 Sample❑ Title Company -- - - <br />— <br />❑ Address -- — Tele No. <br />Sewage System Inspection <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 <br />Title _ <br />Date <br />FOR DEPARTMENT USE ONLY <br />1-1 M ,—.— 1 A pacaived 9v January 31 ❑ July 1 & Received By July 31 <br />Fee is L)Ue: U ANNUALLT <br />u rc� <br />a <br />—_ - <br />REMIT <br />BILLING <br />REMITTANCE <br />$ <br />AMOUNT DUE <br />CHECKED <br />BASE <br />EXPLANATION <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEE <br />J6'1, J 4� <br />n of (-M, <br />7 ; <br />LESS <br />r ,✓� <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br />- APPLICANT—RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAYELTON AVE., P.O. Box 2009 STOCKTON, CA 95201 <br />