Laserfiche WebLink
` Applications Will Be Pr sed When Submitted Properly Completed. Be STo Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND.rOR IF VEHICLE INVOLVED GIVE <br /> APPI ICAC11%AND/OR FOOD ESTABLISHMENTS,HOUSING Make TV <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING MaeNTL C> -- <br /> BR16KER AND/OR REAL ESTATE INSPECTIONS Lic. No. — <br /> IncNSE AND/OR POULTRY RANCHES AND KENNELS Regist, NO._ <br /> 3TRATION MISCELLANEOUS SERVICES g <br /> 1. .BER <br /> ~r Type Permit/Servic RR,e�1�ested: _ _ SLiC]ckyUJ•C1,o-lor <br /> '3-7-Application Date— uesppearPermit <br /> t <br /> n_ <br /> i Applicant Name IA.�F.X�. LS Ad r ss <br /> D <br /> i B sines Tele one No. — Emergency Telephone No. <br /> 'a Property Location/ d, dr alla- <br /> `Property Owner _._ Address <br /> 4Operator's Name Address H66 1`0 A42 Lj�;r Cyr <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 Cl 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 /> WatertSS pply Source Animal Waste Dispos Method <br /> 6. ;.CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE — ' — Oh <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection 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. Q <br /> APPLICANTSSIGNATURE X L� Titl r ate ��L3 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Receiv By Januar 31 ❑ July 1 A Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE 1 AMOUNT <br /> 35 <br /> FEE -4' n ML/ e-w s0 <br /> PRORATION s�G WI�tQSS �Gl S /lYI 3-5--Q-0 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHERf l� <br /> (1-7 <br /> Receive by Dale Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.So.2009 STOCKTON,CA 95201 <br />