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Applications Will Be Pr ed Whew Submitted Properly Completed. Be SSign The Application. <br /> APPLICATION Us <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR F000 ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> KER AND/OR REAL ESTATE INSPECTIONS LIC. No. <br /> FSE AND/OR POULTRY RANCHES AND KENNELS <br /> STRATION MISCELLANEOUS SERVICES Reglst. No. <br /> I. .BER Color <br /> [Application Date r� o®p Business/Name To Appear On Permit rn4�tXy �u� 0g � <br /> 7 ' L--O�.✓�1n��i <br /> FI Type Permit/Service Requested: /✓ 77JY WiLLL 7JTO AA XIIVC � `rTa'G,e.r° rCi1%1aa�— <br /> aA pH ant Name -rJo Address 7-22? 51&90. Oe <br /> u �A". Business Telephone No.9V W-Y`0l6.r Emergency Telephone No. �1'J " <br /> %Property Location/Address y+/Rtc- ?,CAyt42 - q0 L/S if Fc>u G-T <br /> d Property Owner Address <br /> :70perator'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 RECE VEp <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) FEU <br /> 4. RECREATIONAL HEALTH 11 SWIMMING POOL 11 SPA ❑ WADING POOL 11 NATURAL BATHING PLACE <br /> 0:ECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds ,ENvIRONME <br /> ENNEL/Runways /Animal Population No. No. of Confining Cages—�fl.�Lar�,EgL� <br /> Sewage Disposal MethodTH <br /> Solid Waste Disposal Method <br /> Wateerr Su�Source Animal Waste Disposal Method <br /> 6. Cly ONSULTATION FEE 2'� Or/ein��cC S2 '�< T r.��Vs��fti ftlir t��✓ <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 ules an r gulati o the San Joaquin Local Health District. LL Cc <br /> APPLICANT'S SIGNATURE X Title l0 Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 3 Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE sa,s sa- <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ' <br /> a-iiLA- <br /> Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered <br /> �\ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 1009 STOCKTON,CA 95201 <br />