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• Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> ' <br /> Al RONMENTAL HEALTH PERMIT/SERVI S <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 /> inENSE AND/OR - POULTRY RANCHES AND KENNELS R ISt. No. <br /> 3TRATION MISCELLANEOUS SERVICES eg --- <br /> 1. .aER —. Color <br /> f Application Date L' �C / Business/Name To Appear On Permit <br /> FI Type Permit/Service Requested: <br /> i Applicant Name . r . �^ . Clnlr / Address ?ice/ . !,L•--F-✓/ <br /> °-° i. j•..,,,� ! F'r.� usi esa TBIe hone No. �k `/ =y� <br /> p Emergency Telephone No. <br /> -Property Location/Address ^��^`� �= - �'/'�1N' 2 <br /> i Property Owner k /P:t% % !•i"f7� `� Address <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 /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> F :ENNEVRunways /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method -- <br /> Solid Waste Disposal Method <br /> Water Suppl3r5ciurce _ A/nimal Waste Disposal Method <br /> B. 0-`CONSULTATION FEE it r ^ " -•-� �' r ! �. 2v_ <br /> T. ❑ .PLAN CHECKING FEE <br /> S. REAL ESTATE <br /> REQUEST: Water Well Inspection El sample[] Title Company <br /> Sewage System Inspection - ❑ Address Tele. No. <br /> Escrow No. <br /> Seller Seller Address <br /> Telephone No. Seller Agent Name <br /> 'a 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 /> i <br /> APPLICANT'S SIGNATURE X Title Dat �7 <br /> FOR DEPARTMENT USE ONLY \ <br /> Fee Is Due: 13 ANNUALLY ❑ PER UNIT ❑ PER SITE 13 EACH El January 1 A Received By January 31 ❑ July 1 Received By July At <br /> BILLING REMITTANCE S MIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DU NECKED <br /> L A OUNT <br /> FEE , {! /1 //:l?, -D<. .b/ •1 cx. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ✓VY G�n� <br /> OTHER R°( G <br /> OTHER !:.':.'G/ <br /> !� I <br /> Received by Data pt No. Permit No. tae ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.N N AVE.,P.O.Box 2009 STOCKTON.CA SS2e <br />