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Applications Will Be Fair --ed When Submitted Properly Completed. Be Sur- '­r Sign The Applicayl5h. <br /> APPLICATION %%,L "'� <br /> S <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS LIC. NO. -----.-- <br /> irFNSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES RegiSl. NO. <br /> I. 8ER —_- ___. _.__ Color <br /> Application Date_-1— 9_�_12� Business/NaW To Appear On Permit <br /> ViType Permit/Service Requested: --------- <br /> i Applicant Name ��c� /C!' ZIT vuw _ Address Qa�r •!DLA 177tDh <br /> —_.._ Usineseleph <br /> Tone .'. Emergency Telephone No. <br /> L Property Location/Address (A � - �' r � <br /> iProperty Owner_ _ —__ Address <br /> -LOperator'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 PAYMENTpp pp <br /> ❑ HOTEL/MOTEL/No. of Units — ❑ CERTIFICATE OF OCCUPAIN6;E f V E D <br /> ❑ MOBILE HOME PARK/No. of Spaces JAN <br /> 4 <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) 13 CHEMICAL H J 1J - <br /> 11 PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) ENVIRONMENT,^ <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BAKRWTgLACE <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 Supply Source Animal Waste Disposal Method <br /> S. ❑ CONSULTATION FEE <br /> 7. &KPLA N CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUESTWater 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 les and lations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ---_.-___. — Title Date--- <br /> FOR <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July t A Recened By July 3'. <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Dale `iCeipt No. Permit No. Is! a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA AVE.,P.O.Boa 1009 STOCKTON,CA 95]0 <br /> L <br />