Laserfiche WebLink
M. ,. <br /> h Applications Will Be Process lfhen Submitted Properly Completed. Be Sure T%n The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES IF VEHICLE INVOLVED, GIVE <br /> 1 <br /> ENGINEER'S AND/OR FOOD ESTABLISHMENTS,ROUSING Make , <br /> APPLICANT'S AND/OR PUBLIC POOLS,WATER SAMPLING Lic. No. <br /> CONTRACTOR AND/OR REAL ESTATE INSPECTIONS <br /> BROKER AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> CENSE AND/OR MISCELLANEOUS SERVICES Color <br /> 3TRATION <br /> I. 8ER <br /> fApplication date <br /> -�j� Business/Name To Appear On Permit <br /> ,,,Type Permit/Service Requested: Address <br /> It Name �� '` v� 41L <br /> U - � l y53z� Business Telephone No. <br /> Emergency Telephone No. <br /> a C �IcUKe-L�� <br /> `Property Location/Address _. Address <br /> 'i a Property Owner 2 Address <br /> - Operator's Name Restaurant, Maximum Seating Capacity <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage ❑ MEAT MARKET <br /> El RESTAURANT IJ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE <br /> ❑ COMMISSARY 13 ICE PLANT 11 BAKERY <br /> 11 FOOD PROCESSING PLANT E] BAR ❑ ITINERANT RESTAURANT <br /> 1:1 ROADSIDE FOOD STAND ❑ LIQUOR STORE 11 FOODO PTOV <br /> — E] FOOD VENDOR <br /> 11 CONFECTIONARY STORE El FOOD SALVAGER ❑ MOBILE FOOD PRE . UNIT ❑ VENDING VEHICLE <br /> 13 VENDING MACHINES/No. of <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ HOTEL/MOTEL/No. of Units <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) 11 NATURAL BATHING PLACE <br /> 4. RECREATIONAL HEALTH C3 SWIMMING POOL ❑ SPA 11 WADING POOL <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, (3) CONSULTATION FEE f I r SLt L tt <br /> 7. ❑ -PLAN CHECKING FEE <br /> B. 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 rulesand re ulations of the San Joaquin Local Health District. <br /> IzdAPPLICANT'S SIGNATURE X c Title ( cCoh) Date � ��A <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNI7 ❑ PER SITE ❑ EACH ❑ January I &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ <br /> REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> y}..(�Ic AMOUNT <br /> FEE Jyof'I\ ,C) I ' LJ 7. <br /> -7 A� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY }}-� f1 <br /> OTHER T —62-5z-/k �•C f' IC 3130 -39 <br /> OTHER �F 2. 2D <br /> L <br /> ceived by Date Receipt No, Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZ€LTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />