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Applications Will Be Processed When Submitted Properly Completed. Be Sur To Sign The Application. APPLICATION IVIRONMENTAL HEALTH PERMIT/SERVIC-ES ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE APPLICANTS AND/CR FOOD ESTABLISHMENTS,HOUSING Make -- CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING BROKER ANDiOR REAL ESTATE INSPECTIONS Lic. No. . rFNSE AND/OR POULTRY RANCHES AND KENNELS Regist, NO.__ iTRATION MISCELLANEOUS SERVICES Calor I, r3ER - Application Date / Business/Name To Appear On Permit 'TGC -Lo Type Permit/Service Requested - a Applicant Name Address- 28L S G' rvo rlt _ Business Telephone No. U Emergency Telephone No. CL Property Location/Address Property Owner _-_ __ Address _ a Operator's Name _--- __ — Address — 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT ❑ CONFECTIONARY STORE ❑ FOOD 'SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR ❑ VENDING MACHINES/No. of _ --- 1:1 MOBILE FOOD PREP UNIT ❑ VENDING VEHICLE ❑ FOOD CROP HARVESTING/No. of Field Employees - - ----- ALL APPLICANTS: Total Employees Including Operators - -- 2. HOUSING ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY ❑ MOBILE HOME PARK/No. of Spaces _ 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL. ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER NO OF PUBLIC SERVED (Connections) — 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds r :ENNEL/Runways _ — /Animal Population No. _ _ No. of Confining Cages Sewage Disposal Method - Solid Waste Disposal Method - Water Supply Source Animal Waste Disposal Method 6. C -'CONSULTATION FEE ! /1 r r � — 7. ❑ PLAN CHECKING FEE S. REAL ESTATE REQUEST, Water Well Inspection 13 Sample Title Company - Sewage System Inspection ❑ Address __ Tele. No. Escrow No. - — Seiler Seller Address Telephone No.— _ — Seller Agent Name - Service Request For Date - - -� I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. �c� c-o K # 1.3(o APPLICANT'S SIGNATURE X Title — Date FOR DEPARTMENT USE ONLY Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE I rPv, LESS PRORATION PLUS PENALTY -F- OTHER OTHER Received by Date Receipt No. Permit No Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201