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5AA69 /783 <br /> Applications Will Be PryE�ssed When Submitted Properly Completed. Be S To Sign The Application. <br /> . APPLICATION a 110MP# eLE/AJC <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/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TRATION MISCELLANEOUS SERVICES 9 <br /> I, ,BER Color <br /> f Application Date ri Business/Name To Appear On Permit <br /> FI Type Permit/Service Re u ted: <br /> `Applic nt Na Q'✓ !s Address <br /> M us Lis I hon No. 3 Emer cy Telephone No. <br /> 111. <br /> `Property Location/Addre'ss a <br /> iProperty Owner Addr ss <br /> :70perator'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 EISWIMMING POOL ❑ SPA 11WADING POOL 11NATURAL BATHING PLACE <br /> S. 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 /> WateSoTuArc7e1WAn'7 � sposal Meo <br /> 6. LEE _ <br /> 7. ❑ PLAN CHECKING FEE <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection 11 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 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 D �Z <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: 11 ANNUALLY ❑ PER UNIT PER SITE 11 EACH El January 1 &Received By January 31 ❑ Julece2&ll J I <br /> BASE EXPLANATION <br /> BILLING REMITTANCE $ MIT DATE DATE REMITTED AMOUNT DUE HE KE�y O NT <br /> ,LR <br /> FEE <br /> N `„,/ <br /> �o.c. �T <br /> alk <br /> LESS n <br /> PRORATION <br /> PLUS <br /> PENALTY 'FvY'Lfi(/ <br /> OTHERG <br /> OTHER f <br /> Pecefvec tty - Date r pt#No. !�Fenno No Issua ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 -- <br />