FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

Applications Will BePr essed When Submitted Properly Completed. Be S e To Sign The Application. APPLICATION ENVIRONMENTAL HEALTH PERMIT/SERVICES ENGINEER'S AND-OR IF VEHICLE INVOLVED, GIVE APPLICANT'S ANO/OR FOOD ESTABLISHMENTS,HOUSING Make CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. --- -- _ -_—_.- - .IrENSE AND/OR POULTRY RANCHES AND KENNELS Regist. NO, 3TRATION MISCELLANEOUS SERVICES - ------------" I. .r3ER ------ ---------- Color ---- (Application DateJDI- _ Business/Name To Appear On Permit Type Permit/Service Requested:- INS SiT7 0,l) 0.4-- a Applicant Name ��v1 G.�2�LG r�_ _ _____ Address 15� l�adL-'71_ ST /a�L G►Ile aBusiness Telephone No. Emergency Telephone No. a Property Location/Address W, SiDE/�s� � G�iLT /�i2L✓�27�� / a Pro ert Owner r/ - ---- ---- -- / �/ mwc'/�-L97'e �'T CX/7,0 - p y �!�/n[�� _ Address 229/ -LOperator's Name 516-6— J' Address ' L�S� 51�u-�N 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR ❑ VENDING MACHINES/No. of __ ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE ❑ FOOD CROP HARVESTING/No. of Field Employees ALL APPLICANTS: Total Employees Including Operators 2. HOUSING ❑ HOTEL/MOTEL/No. of Units ____ ❑ CERTIFICATE OF OCCUPANCY ❑ MOBILE HOME PARK/No. of Spaces -- 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER NO. OF PUBLIC SERVED (Connections) - -- --- -- - -- - 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds F :ENNEL/Runways /Animal Population No. __ No.of Confining Cages Sewage Disposal Method- -- Solid Waste Disposal Method ---- ��- Wateerr,Su Source _ Animal Waste Disposal Method 6. � CONSULTATION FEE - - 7. ❑ PLAN CHECKING FEE B. REAL ESTE Inspection d ai l REQUEST: Sample❑ Title Company Sewage System Inspection ❑ Address _______ _-- -___-_ Tele. No. Escrow No. - ----- -- - - Seller __ ---_ -_______ .--- -- _ Seller Address _ N4- Telephone No. - Seller Agent Name Service Request For Date -- - -- --- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. APPLICANT'S SIGNATURE X __..-_ _ - Title�2w �C SCI6-A Date 101-y7/J7 FOR DEPARTMENT USE ONLY Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER c� OTHER 70) Receivebg [fatel Receipt No. Permit No Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520.