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Applications Will Be,yrocessed When Submitted Properly Completed. Br Sure To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR <br /> APPLICANT'S ANDD/O FOOD ESTABLISHMENTS.HOUSING IF VEHICLE INVOLVED, GIVE <br /> BROKER AND/OR <br /> AND/OR PUBLIC POOLS.WATER SAMPLING Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONS <br /> .IrE TRAND/OR POULTRY RANCHES AND KENNELS LiC. NO. <br /> 3 <br /> TRATION <br /> I, .dER MISCELLANEOUS SERVICES Regist. No. <br /> _ <br /> Color <br /> f Application Date a s 6 Business/Name To Appear On Permit -V" <br /> FI Type Permit/Service Requested: - - <br /> uApplicant Name P Address _PJT ICL-(�L. <br /> n Business Telephone No. Emergency Tel phone No. <br /> `Property Location/Address <br /> <Property Owner <br /> 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 /> 5. 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 /> Water Sweply Source Animal Waste Disposal Method <br /> B. CONSULTATION FEEI.�/iHa'N(1�yJ � P1X7 s � <br /> 7. ❑ .PLAN CHECKING FEE y <br /> S. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 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 <br /> Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 A Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> ^ — DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE HAS, AMOUNT_ <br /> LESS <br /> PRORATION <br /> O PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No, <br /> Issuance Is oDelivered i <br /> � APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95291---- <br />