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APPLICANT'S AND/OR rUUU rSIAu"SMMEMTS, dUSiNG Make <br /> CONTRACTOR ANDIOR PUBLIC POOLS,WATERS IMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIOl S Lic. No. . <br /> Ir.ENgE AND/OR POULTRY RANCHES AND ENNELS Reglst. No. <br /> 3TRATION MISCELLANEOUS SERYIC S <br /> I. .r3ER Color <br /> rApplication Date—6 1 Z —f L Business/k4ame To Appear On Permit <br /> ,nType Permit/Service Requested: -- z — <br /> a Applicant Namez,Q res1 <br /> Busin ss Telephone No._� �� �' J o. <br /> ,a <br /> IL Property Location/Address <br /> _Property Owner — _ Addres <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 /> ❑ FOOD 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 /> C] 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 /> .ENNEL/Runways /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> P Y J ... p od <br /> W ter Su pl Source Animal W le Is osa <br /> 6.�CONSULTATION FEE ': - ` i1LG <br /> 7/❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ Sam ple❑ 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 &Received.By January 31 ❑ July 1 &Received By July 31 <br /> BREMIT <br /> BILLING REMI TANCE $ <br /> BASE EXPLANATION DATE ATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT_ <br /> FEE rr5L <br /> LESS <br /> PROFIATION <br /> PLUS <br /> PENALTY JJ <br /> OTHER + . <br /> cm gulak- <br /> OTHER •r� <br /> f� 1 <br /> ei tl by t9/�(Da eceipt No• Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />