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Complete Be S« To Sign The Application. Applications Will Be PrW ed When Submitted Properly Comp APPLICATION hNVIRONM'ENTAL HEALTH PERMIT/SERVICES _ IF VEHICLE INVOLVED,GIVE FOOD ESTABLISHMENTS,HOUSING Make ENGINEER'S AND/OR Lic. No. APPLICANT'S AND/DR PUBLIC POOLS.WATER SAMPLING CONTRACTOR AND/OR REAL ESTATE INSPECTIONS Regist. No. BROKER AND/OR POULTRY RANCHES AND KENNELS .Ir'FNSE AND/OR MISCELLANEOUS SERVICES Color 3TRATION G I, dER IM's J V Business/Name To Appear On Permit [Application Date IFType Permit/Service Requested: Address Emergency Telephone No. c Applicant Name ' Business Telephone No. v J IProperty Location/Address Address Property Owner ' _ Address Operator's Name Restaurant, Maximum Seating Capacity Total Building Sq. Footage ❑ MEAT MARKET 1. FOOD ESTABLISHMENTS El MARKET WHOLESALE ❑ BAKERY ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ ICE PLANT ❑ ROOD PROCESSING PLANT ❑ COMMISSARY ❑ BAR ❑ ITINERANT RESTAURANT 13 ROADSIDE FOOD STAND LIQUOR STORE D FOOD VENDOR ❑ FOOD DEMONSTRATION ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ VENDING VEHICLE ❑ MOBILE FOOD PREP. UNIT ❑ VENDING MACHINES/No. of — ❑ FOOD CROP HARVESTING/No. of Field Employees — — — ALL APPLICANTS: Total Employees Including Operator 2. HOUSING ❑ CERTII ❑ HOTEL/MOTEL/No.of Units ❑ MOBILE HOME PARK/No. of Spaces --.-- -— ❑ CHEMICAL Y 1 3. WATER QUALITY 11 ER SAMPLE (Bacterial} ❑ WATER HAUL1 V [I PUBLIC WATER SYSTEM El SURFACE WATER SUPPLY NO. OF PUBLIC SERVED (Connections) ❑ SPA ElWADING POOL . If 4. RECREATIONAL HEALTH [ISWIMMING POOL 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds r ',ENNEL/Runways ---- /Animal Population No. _ — Sewage Disposal Method -- Solid Waste Disposal Method ----- — Animal Waste D Water Supply Source — g. ❑ CONSULTATION FEE 7. ❑ PLAN CHECKING FEE B. REAL ESTATE Title Company — REQUEST: Water Well inspection❑ 5a 13 Address Sewage System Inspection Escrow No. — Seller Address Seller Seller Agent Name — — Telephone No. -- — — — Service Request For Date I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state la , and rules anpaglulations of the San Joaquin Local Health District. G Title ' Date APPLICANT'S SIGNATURE X -- FOR DEPARTMENT USE ONLY ❑ PER SITE ❑ EACH 1:1 January 1�Received By January 31 ❑ July 1 &ReceivedJuly 31 REMIT Fee IS DUB: ❑ ANNUALLY ❑ PER UNIT REMITTANCE S AMOUNT DUE CHECKED BILLING ITTED BASE EXPLANATION DATE DATE REMAMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER {` 1 t - C)— �� Issuance Date Mailed Delivered — �~ Date Receipt No. Permit No. Received by 1601 E.HA2ELTON AVE.,P.O.Box 2009 STOCK7DN,GA 955 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES