Laserfiche WebLink
Applications Will Be P�d When Submitted Properly Completed. Be` <br /> Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES IF VEHICLE INVOLVED, GIVE <br /> FOOD ESTABLISHMENTS,HOUSING Make —� <br /> ENGINEER'S AND/OR Llc. NO. <br /> APPLICANT'S AND/OR PUBLIC POOLS,WATER SAMPAN <br /> CONTRACTOR AND/OR POOL RY RASTATE INSPECTIONS <br /> BROKER AND/OR POULTRY RANCHES AND KENNELS <br /> Regis/. NO. <br /> .IfENSE AND/OR MISCELLANEOUS SERVICES Color <br /> 3TRATION 11� <br /> I. <br /> SER SY\ <br /> ` Busi ass/Name To Appear On Permit <br /> Application Date <br /> .Type Permit/Service Requests <br /> Address <br /> a Applicant N me Business Tel hone o. Rn< �1�Tz'- a2 Emergency Telephone No. <br /> U <br /> J <br /> `Property Location/ dress Address <br /> aProperty Owner Address <br /> -Operator's Name Total Building Sq. Footage Restaurant,Maximum Seating Capacity <br /> ❑ FOOD MARKET WHOLESALE D MEAT MARKET <br /> 1. FOOD ESTABLISHMENTS D BAKERY <br /> D RESTAURANT 13 FOOD MARKET RETAIL D ICE PLANT <br /> ❑ COMMISSARY ❑ ITINERANT RESTAURANT <br /> ❑ BAR <br /> D FOOD PROCESSING PLANT D LIQUOR STORE D FOOD VENDOR <br /> D ROADSIDE FOOD STAND ❑ FOOD SALVAGER D FOOD DEMONSTRATION ❑ VENDING VEHICLE <br /> D CONFECTIONARY STORE D MOBILE FOOD PREP. UNIT <br /> D VENDING MACHINES/No. Of <br /> D FOOD CROP HARVESTING/No. of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators ❑ CERTIFICATE OF OCCUPANCY <br /> 2. HOUSING <br /> D HOTEL/MOTEL/NO. of Units <br /> D MOBILE HOME PARK/No. of Spaces DCHEMICAL <br /> 3, WATER QUALITY D WATER SAMPLE (Bacterial) D WATER HAULER <br /> D PUBLIC WATER SYSTEM D SURFACE WATER SUPPLY <br /> NO. OF PUBLIC SERVED (Connections) <br /> POOL <br /> D SPA ❑ WADING POOL D NATURAL BATHING PLACE <br /> 4. RECREATIONAL HEALTH D <br /> ❑ POULTRY FARM/Maximum No. of Birds <br /> S. VECTOR CONTROL �onfining Cages <br /> r :ENNEL/Runways /Animal Population No. -- <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method Animal Waste Disposal Method <br /> Water Supply Source <br /> B, ISI CONSULTATION FEE <br /> 7. D PLAN CHECKING FEE <br /> B. REAL ESTATE Title Company Tele. No. <br /> REQUEST: Water Well Inspection SampleD Address <br /> Sewage System Inspection <br /> Escrow No. Seller Address <br /> Seller <br /> Seller Agent Name <br /> Telephone No. <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 law and rules and regulations of the San Joaquin Local Health District. Date <br /> Title <br /> APPLICANT'S SIGNATURE X <br /> FOR D T NT USE ONLY <br /> By July 31 <br /> Fee IS Due: ❑ ❑ <br /> uly I <br /> ANNUALLY PER UNIT PER SITE ❑ EACH REMITTANCE , 8 ReceREMIT <br /> 13 January lV$ BY January at AMOUNTJDUE 8 Received CHECKED <br /> BILLING DATE REMITTED AMOUNT <br /> BASE EXPLANATION DATE <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER CJ <br /> Permit No <br /> Date Receipt NO. . Issuance Date Mailed Delivered <br /> Receive Y 1301 E.H6-20 <br /> AZELTON AVE.,P.O.B09 STOCKTON,CA 99101; <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />