Laserfiche WebLink
Applications WIII Be Prf sed When Submitted Properly Completed. Be S, TO Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING IF VEHICLE INVOLVED, GIVE <br /> Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING - <br /> BROKER AND/OR REAL ESTATE INSPECTIONS LIC. No. <br /> WENSE AND/OR POULTRY RANCHES AND KENNELS C(a <br /> iTRATION ---- MISCELLANEOUS SEflVICESD e No. <br /> t, BER _ r <br /> (Application Date Business/Name To Appear On Permit _ <br /> ,n Type Permit/Service Requested: <br /> UAp ant�ia, e NSIGi�/lo GD�/CCf/i/e Address—l-WJ .00r _5";'J, Ip cl <br /> -4- — Business Telephone No._�_,L5____ y/� emergency Telephone No. <br /> `Property Location/Address <br /> aProperty Owner___Z9re0 Address S/� S. `/c�c+�tir ZA <br /> -[Operator's Name ��Li�Ps _ Address —��,s �_7 ;W 7___ <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 ❑ BARC)-ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION FOOD VENDOR <br /> ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. U ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees - ��so/��, <br /> ALL APPLICANTS: Total Employees Including Operators Yt!�1uCi!`�'tC.+ <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 /> F ;ENNEL/Runways /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> WatFu'*PLAN <br /> ource Animal Waste Disposal Method <br /> 6. CONSUL <br /> ONSULTATION FEE <br /> 7. CHECKING FEE <br /> 8. 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 Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> • AMOUNT <br /> FEE3}i 0D -- <br /> LESS , <br /> PRORATION <br /> PLUS <br /> PENALTYpl IFD A(`T <br /> OTHER DAY FROM BILLING DATE, �1JJ- <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />