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ENG,NEER.s AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> APPLICANTS ANO/PAIF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR FO00 ESTABLISHMENTS,HOUSING <br /> BROKER AND/OR PUBLIC POOLS,WATER SAMPLING Make <br /> I-ENSE ANO/OR REAL ESTATE INSPECTIONS <br /> 3TRATION POULTRY RANCHES ANO KENNELS LIC. No, -_ <br /> I. .dER _ _ MISCELLANEOUS SERVICES Regist. No. - <br /> Color <br /> (Application Date Business/NamTo pearQnPer t <br /> in <br /> Type Permit/Service Requested: �W_ _.— <br /> . u Applicant Name / <br /> -- Address SIA <br /> a _—_ - ---- Business Teleptione No Emergency Telephone No. <br /> ,(Property Location/Address _2"U - - <br /> Property Owner — - - --- <br /> --- - — Address S� <br /> Operator's Name /'A -- — `— — - — — <br /> 1. FOOD ESTABLISHMENTS - Address — <br /> Total Bung Sq, Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY <br /> 1:1 ❑ ICE PLAINT C1ROADSIDE FOOD STAND El LIQUOR STORE El BAR BAKERY <br /> 13CONFECTIONARY STORE C1FOOD SALVAGER 11FOOD DEMONSTRATION ❑ FOOD VENDOR TAURANT <br /> ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> 40 FOOD CROP HARVESTING/No. of Field Employees <br /> 4 ALL APPLICANTS, Total Employees Including Operators <br /> 2. HOUSING -- — - <br /> ❑ HOTEL/MOTEL/No. of Units <br /> ❑ MOPILE HOME PARK/No. of Spaces - ❑ CERTIFICATE OF OCCUPANCY <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 /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds _ <br /> :ENNEL/Runways _ /Animal Population No. <br /> p <br /> Sewage Disposal Method _ No. of Confining Cagesl-- <br /> Solid Waste Disposal Method -- - - - p,&Y <br /> Water Supply Source <br /> 6. ❑ CONSULTATIONFEE <br /> Animal Waste Disposal Method <br /> --_� - <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE REQUEST Water Well Inspection SamP le❑ Title Company �NVIRONMENTAt HEALTH <br /> _ _ --PERMIT <br /> Escrow <br /> Sewage System Inspection ❑ Address <br /> - <br /> Escrow No —— —Tele. No. <br /> - -- - <br /> Seller Seller Address <br /> Telephone No. -- --_-�— Seller Agent Name - ----- <br /> Service Request For Date — - <br /> I hereby certify that I have prepared th' lication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, nd rules and ulations� the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X Title <br /> Date— f �_C S' <br /> OR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i d Received B <br /> ---��� Y Januar Y 31 ❑ July/ d Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> — — -- — DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE --- — — — ----- AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS, <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Rece,ved by Date Receipt No ----1 rrn,i No -- -- -- - -- <br /> e Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1501 E.HAZ€ETON AVE.,P.O.Box 2009 STOCKTON.CA/520 <br />