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property Gompleted, Be <br /> essed When Submitted Prop T{ON <br /> APPilcatlons 6 ­ <br /> will 8e F AQPLICA <br /> IF VEHICLE INVOLVED, GIVE <br /> ENVIRONMENTAL HEALTH PERMITISERViCE5 Malce <br /> EOOO ESTABLISRMENTS.HOUSINGLiG ND. <br /> ENGaNEER'S AND:DR PUBLIC POOLS,WATER SAMPLING Rc No Na. <br /> APPLICANT'S AND'OR REAL ESTATE INSPECTIONS _. <br /> CONTRACTOR AND'OR POULTRY RANCHES AND KENNELS Color - <br /> BROKER ANDrOR MISCELLANEOUS SERVICES <br /> irFNSE AND'OR <br /> 3TRATiON <br /> dER1 <br /> ear n OPermit <br /> Business/Name To APP <br /> Application Date _--.- s Address <br /> 1-Type Permit/Service Recyie9ted: � '�vG Emergency Telephone NO _-- <br /> �! Business Telephone N0. <br /> a Applicant Name <br /> - - -- Address - - <br /> LProperty Location/Address - <br /> erf Owner - Address <br /> a Prop Y _ -, - --- Restaurant,Maximum Seating Capacity <br /> Operator's Name Total Building Sq. Footage ❑ MEAT MARKET <br /> 1. FOOL) ESTABLISHMENTSFOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ BAKERY <br /> ❑ RESTAURANT C3 BAR❑ ICE PLANT ❑ ITINERANT RESTAURANT <br /> ❑ FOOD PROCESSING PLANT COMMISSARY <br /> ❑ LIQUOR STORE ❑ FOOD DEMONSTRATION 11 Fool) VENDOR <br /> ❑ ROADSIDE FOOD STAND ❑ FOOD SALVAGER ❑ VENDING VEHICLE <br /> ❑ CONFECTIONARY STORE 11 MOBILE FOOD PREP UN <br /> iT <br /> ❑ VENDING MACHINES/No. of -- - - - <br /> ❑ to ees - -FOOD CROP HARVESTINGf Field <br /> Employees <br /> mpors_ - <br /> - <br /> loyees <br /> ALL APPLICANTS. Total Employees <br /> ❑ CERTIFICATE OF OCCUPANCY <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units ------- <br /> ❑ MOBILE HOME PARK/No. of Spaces - - Cl CHEMICAL <br /> 3 WATER QUALITY C3 WATER SAMPLE (Bacterial) 13WATER HAULER <br /> ❑ PUBLIC WATER SYSTEM [3 SURFACE WATER SUPPLY <br /> NO OF PUBLIC SERVED (Connections) <br /> NG POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 4. RECREATIONAL HEALTH <br /> g. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds No of Confining Cages <br /> r -.FNNEL/Runways <br /> /Animal Population No. . - <br /> - - - - - - ----- - - - --- - -- - <br /> - - - <br /> Sewage Disposal method - - --------- <br /> Solid Waste Disposal Method -- -- - Animal Waste Disposal Method <br /> — - <br /> Water Supply Source - --- - - - <br /> 6. ❑ CONSULTATION FEE _.�_ — - - ----- -- --- <br /> 7. PLAN CHECKING FEE <br /> 8. REAL 'ESTATE <br /> ❑ Title Company . - - — — ---- ---- - - <br /> REQUEST Water Well Inspect ian� Sample Tele. No. <br /> Sewage System Inspection Address - - - ------ <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 aCordance 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 I S Received By war 31 <br /> --- -- _-- _ y El July 1 &ReCe,rea ey Ju+y 31 <br /> BILLING REMITTANCE S REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> ---�- — AMOUNT <br /> FEE - - - - ----- _— --- -- ���_ <br /> LESS <br /> PRORATION �J — --- -- -- <br /> PL us <br /> PENALTY -_-- _--_---- -- ------ <br /> OTHER <br /> OTHER <br /> Hret�rve•n I� / Osie b ce�>4 No Permel NO 1 2 Dake`----�-_ <br /> y iAAar+ad =--��- -.-_____ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRON141IF NTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON Ai DOCKTOd - - <br /> Boa 2f30g STOCKTON,CA 95207 <br />