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Applications Will Beed When Submitted LICATION Completed. Be qur o Sign The Application. <br /> P ^. ENVIRONMENTAL HEALTH PERMIT/SERVICES IF VEHICLE INVOLVED,GIVE <br /> ENGINEER'S AND/OR FOOD C POOLISHMEHTS.HOUSI�O Pfeaist.e <br /> APPNCANT'S ANO/OR PUBLIC POOLS,WATERSAMPLI NOCONTRACTOR AND/OR REAL ESTATE INSPECTIONSBROKER AND/OR POULTRY RANCHES AND KENNEL No. <br /> .ICENSE AND/OR MISCELLANEOUS SERVICES Color <br /> STRATION <br /> I. .dER --. <br /> [Application Date _ Business/Name To Appear On Permit <br /> ,xType Permit/Service Requested: Co AddressStkn <br /> i Applicant Name Emergency Telephone No. <br /> U usines T IephoLle no <br /> Mo—"j JLR <br /> `Property Location/Address <br /> Address <br /> Property Owner <br /> s Address <br /> -Operator's Name Restaurant, Maximum Seating Capacity <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ <br /> ❑ COMMISSARY 13 ICE PLANT BAKERY <br /> ❑ FOOD PROCESSING PLANT ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ ROADSIDE FOOD STAND ❑ F LIQUOR S STORE <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER 11 FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> 11MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ VENDING MACHINES/No, of <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ HOTEL/MOTEL/No. of Units <br /> ❑ MOBILE HOME PARK/No. of Spaces ❑ CHEMICAL <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) <br /> ElPUBLIC 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 No.of Confining Cages <br /> r :ENNEL/Runways /Animal Population No. <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Animal Waste Disposal Method <br /> Water Supply Source —. <br /> 6. ❑ CONSULTATION FEE <br /> 7. ❑ .PLAN CHECKING FEE <br /> a. REAL ESTATE <br /> REQUEST: Water Well Inspection[] Sample❑ Title Company <br /> Sewage System Inspection <br /> ❑ 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 <br /> Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IB Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 A ReceiveddEByl July 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT_ <br /> FEE Ins 5 1 90 $52.50 <br /> LESS <br /> PRORATION <br /> PPLUS <br /> ENALTY PENAL IES WILL Br A PUP" r, r �^ i <br /> ILL IE. <br /> OTHER <br /> OTHER <br /> Mailed Del <br /> a Data ed <br /> ved oy <br /> Gale ceipl No. Permit No. I¢s <br /> APPLICANT—RETURN ALL COPIES TO'. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1001 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA as]Oi� <br /> Recei <br />