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Applications Will Be ssed When Submitted Properly Completed. Be To Sign The Application. <br /> ` 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 /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. -- -- <br /> IrFNSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. _- <br /> 3TRATION MISCELLANEOUS SERVICES <br /> _ Color <br /> I. t3ER -- — <br /> 1" <br /> Application Date ___ __ _ __—_. -___ Business/Name To Appear On Permit <br /> FType Permit/Service Re fed: - - ----- <br /> Applicant Name °g Address 62 O6r -- <br /> Business Telephone No. __ Emergency Telephone No. <br /> a <br /> a Property Location/Address -- <br /> -J Property Owner Address <br /> a <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 ❑ 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 /> 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 /> 6. CONSULTATION FEE <br /> 7, PLAN CHECKING FEE <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection Sample® Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <br /> r 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 I5 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE `REMITTED AMOU—NT <br /> FEE V '✓ — <br /> LESS <br /> PRORAT#ON <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date eipt No Permit No. Iss1W Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boy 2009 STOCKTON,CA 95201 <br />