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Applications Will Be P- sed When Submitted Properly Completed. Be`r "o Sign The Application. <br /> APPLICATION ...� <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER—z;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 /> DENSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TRATION MISCELLANEOUS SERVICES g <br /> I, .BER ------___ Color <br /> (Application Dates `i I . 9 Business/Name To Appear On Permit --- <br /> ,nType Permit/Service Requested: <br /> �1 <br /> a Applicant Name ` \ AddressQ l_Q Po� P.c Tn(� 2ns <br /> 0 ` ` 6�11 Business Telephone No. Qj6-y5 a-a 4 fj I Emergency Telephone No. <br /> IL Property Location/YAddressnbc& c�C TT\ 'hero,% Q �tj1p <br /> a Property Owner ►"tom ProA t c°'1'� cc m�.ng Address Qa�_GSS'11 GCin m�n-CR q`�`oA <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 C3 WATER SAMPLE (Bacterial) El CHEMICAL PAYMENT <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER RECEIVED <br /> NO. OF PUBLIC SERVED (Connections) nntltl <br /> 4. RECREATIONAL HEALTH 13 SWIMMING POOL ❑ SPA ❑ WADING POOL 13 NATURAL BAT*WPLA6Ej981 <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> r :ENNEL/Runways /Animal Population No. No. of Confining C /IRnP,IAAFPI�A.I V <br /> Sewage Disposal Method PERMITTSERVICES <br /> Solid Waste Disposal Method-- <br /> Water Supply Source Animal Waste Disposal Method <br /> 6. CONSULTATION FEE e"cs.t UjCr\C-P1= RAS rb$0L %-&(CLW- FxGr�U(jh(n CancLScll Sr'M`ll\rj of s)Q-F6 (�,�Srbd j& <br /> 7. 11 PLAN CHECKING FEE CJ V <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection C1 Sample 13 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 6LP QTitle 0,31P. Date ak <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 /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ..+ <br /> OTHER <br /> OTHER <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.Box 2009 STOCKTON,CA 95201 <br />