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Applications Will Be Pro('' 9d When Submitted Properly Completed. Be Surr:Ta Sign The Application. w <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR LE VE CLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR " FOOD ESTABLISHMENTS,HOUSING <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> -BP-:-R AND/OR REAL ESTATE INSPECTIONS Lico) i <br /> E AND/OR POULTRY RANCHES AND KENNELS I <br /> 4 RATION MISCELLANEOUS SERVICESC Re � t. No. <br /> I. ZER <br /> COIOr { <br /> I� <br /> (Application Date �B /Napp To. pear On R rmit I <br /> Type Permit/Service quested: _.WdLd — - , <br /> `Applicant Name_4�('�� ress J '—V <br /> Busi s ToCL No. Emergency Telephone No. <br /> 'Property Location/Addr ss <br /> <Property Owner Addre s <br /> [Operator's Name Address 1; <br /> 1. FOOD ESTA HMENTS otal 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 PESTAURANT } <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 s <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY." <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER DUALITY ❑ WATER SAMPLE (Bacterial); ❑ CHEMICAL , <br /> ti y <br />" ❑ PUBLIC WATER SYSTEM © SURFACE WATER SUPPLY ❑ WATER HAULER ' <br /> NO. OF PUBLIC SERVED (Connections) I <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL . ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> t---CTOR CONTROL ❑ POULTRY FARM/Maximum NO. of Birds '? <br /> .ENNEL/Runways /Animal Population No. No.of Confining Cages_ A <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method . — <br /> Water Supply Source imal Waste Disposal Method P i <br /> 6.CONSULTATION FEES <br /> 7. ❑ PLAN CHECKING FEE <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 I 1y <br /> Telephone No. Seller Agent Name --- <br /> Service Request For Date I! <br /> 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 /> E ONLY <br /> FOR DEPARTMENT US <br /> • <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> B - 13 F REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE AMOUNT DUE CHECKED <br /> REMITTED <br /> i'� AMOUNT_ <br /> FEEET- . <br /> LESS <br /> PRORATION <br /> Ar <br /> PLUS <br /> PENALTY -- <br /> a . . �� AS I <br /> OTHER - ;' :.I r• UA f� 3i R t <br /> i <br /> OTHER <br /> Received by - Date - Receipt No. Permit No Issuance Date Mailed Deliveied <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES " 1601 E.HAZELTON AVE.,P.O.Boat 2009 i STOCKTON,CA 95201 g <br />