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r Applications WIII Be ProcWhen Submitted Properly Completed. Be Sure* <br /> ur Sign The Application. <br /> I 41" APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS, HOUSING Make <br /> CON16RACTOR AND/OR PUBLIC POOLS. WATER SAMPLING "- - <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. -- <br /> IrENSE ANO/OR POULTRY RANCHES AND KENNELS <br /> STRATION I MISCELLANEOUS SERVICES Reg St. No. - <br /> I. AER -_- Color <br /> I (Application Date - -------- <br /> Business/Name To Appear On Permit <br /> �Type Permit/Servic Requ�e"sted: �ktEC�[�a.F'--�ltYrlC� y-�-.2 cilP�.J o{ -�.6T15 LC�n21r�.� - 7 <br /> `Applicant NamerncC cf_f _$Ong __®.__ 1- Address l /._ � S�• CIJ�t/C Al, <br /> Business Telephone No. Emergency Telephone No. <br /> i Property Location/Address <br /> Z Property Owner __._._ ._ .___.__-__ Address <br /> I 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 ❑ 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 /> i <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. 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 /> B. ❑ CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection E3 Sample❑ 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 hLreby certify that 1 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 8 Received By July 31 <br /> BILLING REMITTANCE f REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> _ AMOUNT <br /> FEE. &K Feed. <br /> LESS <br /> PRORATION ' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER — -- ---- ---- <br /> -- _ <br /> Ror d by Date nece r1W Permll Nn. Issuance D Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.for 1009 STOCKTON,CA 95201-- <br />