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P y led When Submitted Properly Completed. Be Su 'o Sign The Application. <br /> Applications Be Pro <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENUINEER S 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 Lia. No. <br /> puNSE AND/OR POULTRY RANCHES AND KENNELS Regisl. NO. <br /> 3TRAT10N?7o 3r7 0 1 MISCELLANEOUS SERVICES <br /> I. .BER <br /> .901 J / Color <br /> (Application Date psi ess/Name To Appear On Permit F06A Ew;m-n miya ISE! Gr",—�g-A�e6 <br /> : <br /> Type Permit/Servic Requested: -•-0�7 II <br /> iApp' n ams tldresfs����• n <br /> —� usiness Telephone o.415- Wc2 --g5L0Q Emerge cy Telephone No. <br /> J <br /> iProperty Location/Ad ress <br /> lProperty Owner •5• Address <br /> - Operator's Name <br /> —�' 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 0 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 nn VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/NO. of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators - <br /> 2. HOUSING 1 ' <br /> 11HOTEL/MOTEL/No.of Units L-I CRIIFICATB O�OCCOPANCY <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) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL 6 LATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> r 1ENNEL/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 /> B. ❑ CONSULTATION FEE <br /> T. ❑ .PLAN CHECKING FEE <br /> a. REAL ESTATE I') I,_ <br /> REQUEST: Water Well Inspection Sampled 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 Dae. -: --'— I -- - <br /> I hereby certify that I havepreparedthis application and that the work will be doneinaccordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE ✓r I �� Title*C�� Date <br /> F DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY /LJ/PER UNIT r PER SI E� (�`YJ EACH ❑ January 1 a Received By January 31 ❑ July 1 A Received <br /> By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> LESS <br /> EFEE <br /> ON <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 1501 E.HAZELTON AVE.,P.O.Boa 1009 STOCKTON,CA 95201 <br />