Laserfiche WebLink
Applications Will BePr essed When Submitted Properly Completed. Be S BSER* <br /> To Sign The Application. <br /> APPLICATION <br /> • NVIRONMENTAL HEALTH PERMIT/SER ES <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 /> IrENSE AND/OR POULTRY RANCHES AND KENNELS Regist. <br /> 3TRATION <br /> MISCELLANEOUS SERVICES Color <br /> I. .BER _- --- ------ ------ <br /> /�� GRv Cdin/JAn/�J <br /> iApplication Date_'-"7��� Business/Name To Appear On Permit <br /> u)Type Permit/Service Requested: _ _ -.- <br /> li- <br /> a Applicant Name w' ✓ �C�c C -- - Address � 0 -- <br /> U _ _ _ _ Business Telephone No.-; /05.1 - VS0(2 Emergency Telephone No. - <br /> a Property Location/Address <br /> /3/lOJ/c Sime /�� ad1'i✓r/,9�l TRA2i <br /> Property Owner_-- l�rtl_[ -.�t�� � _ _ Address 2 Z9 i �i1. i?IFI:« 0 e t -i <br /> r,-7 <br /> Operator'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 /> 11FOOD CROP HARVESTING/No. of Field Employees _ ---- <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 /> 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 /> r :ENNEL/Runways -_- _ /Animal Population No. -- No. of Confining Cages <br /> Sewage Disposal Method _ <br /> Solid Waste Disposal Method <br /> _ Animal Waste Disposal Method <br /> Water Supply Source <br /> 6. ❑ CONSULTATION FEE " - <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 - <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 4-,,"-i C/ ��/ t!'17�'1 Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMBASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEET <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER �y <br /> OTHER / ` �7 /C' <br /> Received by Date ReceipttNo. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201- <br />