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Applications Will Be Prr sed When Submitted Properly Completed. Be SITo Sign The Application. <br /> r <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/ORIF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR F000 E$TABIISNMEHTS,HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS, WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. NO. <br /> �nFNSE ANO/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> MISCELLANEOUS SERVICES <br /> STRATTON COIOI <br /> I, eER <br /> (Application Date -- Business/Name To Appear On Permd —__-_.- -- --- - -- " — <br /> 1 TYPe Peyrmit/Sery a equ�essted:� ——— --ZZ I M N ;,T I T� (<490 <br /> iAp licant me _— Address- <br /> 4 , SGD 10 Business T lephone o. _ Emergency Telephone No. <br /> sProperty Location/Atldress <br /> M ASA2sr�nx L F KR - QST �- <br /> Property Owner—P"� '� r I - �� �= Address <br /> -� <br /> Operator's Name - <br /> Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKETIRETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> • FOOD PROCESSING PLANT 11COMMISSARY ❑ ICE PLANT 11BAKERY <br /> ❑ ROADSIDE FOOD STAND <br /> -" ❑-LIQUOR-STORE- - ❑-BAR ' "" -- - - ❑'ITINERANT-RESTAURANT <br /> - <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 — r <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 /> ❑ <br /> 3. WATER QUALITY 11 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 pply Source __ um I �. Animal Waste Disposal Method <br /> 6. CONSULTATION FEE /YA�1.�'1 <br /> 7. PLAN CHECKING FEE <br /> 6. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ Sample❑ Title Company <br /> Sewage System Inspection ❑ Address ENNRQWMENTAL HEAL <br /> Escrow No. _ PERMIT SERVICES <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 Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 A Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT OUE CHECKED <br /> er1� AMOUNT <br /> /�/y /� 11, <br /> FEE �.Vv I' ✓ 11„ I J L/ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Recened by Date �."t No Permit No. Issu Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HALON AVE.,P.O.Box NO STOCKTON,CA 95201 <br />