Laserfiche WebLink
Applications Will Be P seed When Submitted Properly ompleted. Be S To Sign The Application. <br /> _ <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH ERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPXCANT'S AND/OR FOOD ESTABLISHMENTS. MUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> .Ir'li AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TRATION MISCELLANEOUS SERVICAS g <br /> I. ,dER Color <br /> Application Date - l Q Business/Name To Appear On Perm t <br /> a Type Permit/Service Requested: 1 <br /> a Ap licant Nam �— r cul Address—IM 1_ _ <br /> 2 _ — siness T I p ne No Emergency Telephone No. <br /> d <br /> roperty L ation/A re <br /> Property Owner Address <br /> 4 <br /> -Operator's Name Addres <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 /> 0 CONFECTIONARY-STOREELI FOOD SALVAGER- 0-FOODDE ONSTfA-T-4eJ---ii- 0-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 PAYMENT <br /> z. HOUSING RECEIVED <br /> ❑ HOTEL/MOTEL/No, of Units 13 CERTIFICATE Of OCCUPANC <br /> ❑ MOBILE HOME PARK/No. of Spaces f-EB i 0 iouo,j <br /> 3. WATER QUALITY ❑ WATER SAMPLE {Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER ENVIRONMENTAL HEALTH <br /> NO, OF PUBLIC SERVED (Connections) PERMIT/SERVICES <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> :ENNEL/Runways /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Di sal Method <br /> 6. CONSULTATION FEE ) <br /> T. ❑ .PLAN CHECKING FEE <br /> 6. 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 thework 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 UNfT ❑ PER SITE ❑ EACH January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMi TANCE $BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT_ <br /> FEE `, 12- 43`5 31!�.OD <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY �j-� <br /> OTHER .OZ.S Z•O i 1 r�S1/2.548 <br /> OTHER O NAL IES" L BE PPLIED TOP ST DEME ACUNT 4 Ems"•(. <br /> Received ay Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> - f <br />