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Applications Will Be *ed When Submitted Properly Completed. Be 0o Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> IF VEHICLE INVOLVED, GIVE <br /> a ENGINEER'S AND/OR F000 ESTABLISHMENTS,HOUSING <br /> APPLICANT'S AND/OR Make <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING <br /> REAL ESTATE INSPECTIONS LIC. NO. <br /> ( &KICKER AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> irF_NSE AND/OR MISCELLANEOUS SERVICES <br /> STRATION - (color <br /> I. .aER `} <br /> (Application Date f'./�� � Business/Name To Appear On Permit <br /> ,Type Permit/Service Reques d <br /> �'�'" Xn!2 .9fl . y ii-%'?.Ann <br /> a Applicant Name -. -- + <br /> o '7 `- Business Telephone No.— EmergeTel No. <br /> aProperty Location/Address <br /> Property Owner <br /> ii Y'C�gw � /--; . _ Address <br /> a Address <br /> Operator's Name <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 /> 11HOTEL/MOTEL/No. of Units _ 11 CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces <br /> 3. WATER DUALITY ❑ 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 /> r TNNEL/Runways /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Animal Waste Disposal Method <br /> Water Supply Source __ <br /> 6. ❑ CONSULTATION FEE 7- <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST. Water Well Inspection 11 Sample 13 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 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 19 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 A Receiv d By REMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT_ <br /> FEE ✓J _ <br /> ri <br /> LESS f'A -d PIO ,.. <br /> PRORATION I <br /> PLUS <br /> PENALTY ry <br /> OTHER 1('i/ <br /> OTHER <br /> Received by Date pt No. Permit No. Issu ate Mailed Delivered <br /> .__.......� e�...e.,.,, mem.Tn. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,P.O.Boz 3009 STOCKTON,CA 95101 <br />