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Applications Will Be Pidifed When Submitted Properly Completed. Be Sut Sign The Application. <br /> APPLICATION <br /> bISIMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND'OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR - <br /> � F000 ESTABLISHMENTS.HOUSING Make <br /> CONTRACTOR AND/OR �i' x . PUBLIC POOIS,WATER SAMPLING - <br /> q..`'� REAL ESTATE INSPECTIONS LIC No. <br /> FOR AND/OR �"� POULTRY RANCHES AND KENNELS <br /> C�� Reglst NO <br /> E AND/OR . <br /> RATION MISCELLANEOUS SERVICES <br /> Color <br /> i dER (v/ <br /> Application Date �s�1.-- - -0- -- - Business/Name To Appear On Permit - <br /> FType Permit/Servi a Reque ted/:--Sad S�'l (� I I l�� <br /> a Applicant Name �.1��lC'I-L,5�O__ �1M�.-�L1^_u-4'hf-t_ Address <br /> -PILO 3 Bu�ness ._ <br /> Telephone No. _ - . --- - - _ Emergency Telephone No. <br /> Q_a��-I(�yt Qf <br /> --— ---- <br /> .Property Location/Address mac( <br /> Property Owner -P,..G o Address — -- -- --- --- <br /> Operator's Name -----I i __ __ ------ 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 UnitsCERTIFICATE 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 13 SWIMMING POOL 11 SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> CTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds -.----... — <br /> ENNEL/Runways /Animal Population No. — No.of Confining Cages_ <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method --.—_. -- -----_ <br /> Water pply Source _ Animal Waste Disposal Method <br /> 6, CONSULTATION FEE S.fF-E af2*F�LI� .,--Lrl 5 Te C. o--op-1 -�. rrl J'eT1oYci <br /> 7. ❑ PLAN CHECKING FEE <br /> a. REAL ESTATE <br /> REQUEST: Water Well Inspection 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 Dale --- - — ------ ---- --_---- <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 Received By July 31 <br /> -- TINGREM <br /> REMIT <br /> BASE EXPLANATION BILE $ AMOUNT DUE CHECKED <br /> DAREMITTED AMOUNT <br /> _.-FEE -�' s] A V.G.4 —LLss ,J ,�i�T 'r�l N.r PRORATION �iFfx\\�Ac�LL aW-��+—rryiY 1..i. ,1PENALTYPLUS 1%%VI/J 11{ IVI 4:ILLli a�7 A1 <br /> OTHER <br /> OTHER <br /> R evttl ny - —-- -pall - _-- -- P1 No _ Punm No Issu ale Mailed Delivered <br /> APPLICANT RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.111 2009 STOCKTON,CA 95201 <br />