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Applications Will Be Prsed When Submitted Property Completed. Be Su To Sign The Application. <br /> APPLICATION <br /> ' ENVIRONMENTAL HEALTH PERMIT/SERVICES IF VEHICLE INVOLVED, GIVE <br /> ENGINEER'S ANDIOR M <br /> f000 ESTABLISHMENTS.HOUSING Make <br /> APPLICANTS-ANDIOR il� PUBLIC POOLS,WATER SAMPLING Lic. No _ <br /> CONTRACT0*AND%0R REAL ESTATE INSPECTIONS <br /> BROKER AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> Ir.ENSE ANOIOR MISCELLANEOUS SERVICES <br /> Color <br /> ShRATION <br /> .BER <br /> I / /Application Hate Business/Name To Appear On Permit -- - -�- <br /> f � . �- <br /> I,Type Permit/Service equ <br /> _ ested'� c 1 Address- <br /> � <br /> c Applicant Name - L,/ � _ Emergency Telephone No. <br /> U Business Telephone Na. -> <br /> a pp�rty Location/Addres - <br /> Address <br /> Property Owner - <br /> a - Address - - <br /> -[Operator's Name -- - Restaurant, Maximum Seating Capacity <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage MEAT MARKET <br /> 13 RESTAURANT C3 FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE <br /> 13FOOD PROCESSING PLANT [3 COMMISSARY ICE PLANT 11 BAKERY <br /> COMMISSARY ❑ BAR 11 ITINERANT RESTAURANT <br /> ❑ ROADSIDE FOOD STAND 11 LIQUOR STORE 11 FOOD VENDOR <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER El FOOD DEMONSTRATION <br /> ❑ VENDING MACHINES/No. of - - - - <br /> ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees -ALL APPLICANTS, Total Employees Including operators - - - <br /> 2. HOUSING ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ HOTEL/MOTEL/No. of Units -- <br /> ❑ MOBILE HOME PARK/No. of Spaces -- 13 CHEMICAL <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) . <br /> 4. RECREATIONAL HEALTH <br /> ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds - — - <br /> /Animal Population No. - - No. of Confining Cages <br /> � :ENNEL/Runways - -- - - <br /> Sewage Disposal Method - — <br /> Solid Waste Disposal Method <br /> I Source Animal Waste Disposal M od <br /> Water,Suupp y -- - - <br /> 8, W'CONSULTATION FEE t <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> _.�-J <br /> REQUEST: Water Well Inspection[] Sample[] Title Company Tele. No. <br /> Sewage System Inspection ❑ Address -- <br /> Escrow No. - - - <br /> Seiler -_ _.__- - - Seller Address <br /> Telephone No. - - Seller Agent Name <br /> Service Request For Date -- - - - <br /> Ihereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> do <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Rje rilr)? <br /> Title, Date <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> ❑ <br /> PER UNIT F-1PERSITE ❑ EACH C3 January 1 &Received By January 31 C] July 1 &Received By July 31 <br /> Fee IS Due: ❑ ANNUALLY <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY q <br /> OTHER <br /> V4 <br /> OTHER <br /> Receipt No Permit No. Issuance Date Mailed Delivered <br /> Dale <br /> R c ed by i601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 45241 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES _ <br />