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` Applications Will Be Pr#When Submitted Properly Completed. Be S0Sign 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 /> IrENSE AND•OH POULTRY RANCHES AND KENNELS Reglsl- No <br /> 3TRATION MISCELLANEOUS SERVICES <br /> I. .dEF1 Color - <br /> Application Date j�! � , � - - . Business/Name To Appear On Permit <br /> v,Type Permit/Se <br /> a R1leque ted:_-JO1.1 . SA-! 1'i 11 } .0 <br /> <Applicant N1ame .r__4'r !-c D L:Ia-�.. _�u? f-- ' Address <br /> Bu mess Telephone No. _ ___ Emergency Telephone No. -- ------ <br /> aProperty Location/Address -T- -- <br /> ;Property Owner �• o -- Address <br /> r! ---- - - <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 �.rpply Source _ __ _ Animal Waste Disposal Method- <br /> s. /CONSULTATION FEE � ry1, <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST Water Well Inspection 11 Sample Q Title Company _-- - _-- --- - <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 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: Q ANNUALLY ❑ PER UNIT ❑ PER SI i E ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> --— -- - I REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE - --- J -f 1 .G - _ -3 5 a <br /> LESS r r r� J,+e t" r°r ! 1-F. <br /> PRORATION _ I I �� ^ i1 UE IN,(-.._ iY.. <br /> r <br /> PLUS Sr I"l II•. .... <br /> PENALTY V!`.1 l it ��� t3ivL+i — <br /> OTHER <br /> OTHER <br /> -- ----- —---Received by Dalc Receipt No Permit No Isle Dale Mailed Delwered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Rosi 2009 STOCKTON,CA 96201 <br />