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Applications WIII Besed When Submitted Properly Completed. Be o Sign The Appy atirm <br /> APPLICATION 0 <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 'IENGINEER'S AND/OR IF C I LVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING , 1tlake <br /> u f;,J MOKER AND/OR REAL ESTATE INSPECTIONS R E C E I V E ac. No. <br /> v Ir'.ENSE ANO/OR POULTRY RANCHES AND KENNELS RegiSt. NO. <br /> 1 3TRATION MISCELLANEOUS SERVICES DEC 1 QU��yr�+Regis <br /> I, .aER _—___--_—__�_7_/._. Q/� /a 4 1990 <br /> f olor <br /> Application Date. J/QS(O - Bussiinness/Namei3,ear On Permit Ch" <br /> Type Permit/Serviceequ/es _ j7Q_ LZ' 7'1.1_-! r1E CA <br /> `Appli nl Name �_ .Q,µQ/'r� � p�- - '1�LCCAddress <br /> _ 9U�i� Business Telephone No. __ Emerggncy Telepho��N�. <br /> g Propertyperty Locat� ���� /_[JJJ (4,T� <br /> Ir <br /> Property Owner - Address _ <br /> Operator's Name _ 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 /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING ' <br /> ❑ HOTEL/MOTEL/No. of Units Cl 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. _ No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source -__ Animal Waste Disposal Method <br /> 6. Cl CONSULTATION FEE <br /> 7. ZPPLAN CHECKING FEE <br /> S. REAL ESTATE <br /> REQUESTS Water Well Inspection❑ Semple❑ Title Company <br /> Sewage System Inspection -.❑ Address __. __ Tele. No. <br /> Escrow No. ----_ _ <br /> Seller _._--_ Seller Address <br /> Telephone No. Seller Agent Name <br /> Service Request 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 Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS 1 �.0 O <br /> PRORATION ✓ <br /> PLUS <br /> PENALTY I,i A I;L. <br /> OTHER 4F // <br /> OTHER CNAI T <br /> H Fir <br /> DAYS FROM BIL 1 JG U I I F ACCOUNTS 30 <br /> R-r,"M ny Date P No Permit No. Issue to Mailed Delivered v <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRO NTAL HEALTH PERMIT/SERVICES 1601 E.HASEL AVE.,P.O.Boa 2009 STOCKTON,CA 95201---- <br />