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4 <br /> Applications Will Be Prr^tiessed When Submitted Properly Completed. Be G--re To Sign The Application_ <br /> APPLICATION <br /> ENGINEER'S ANGOR ,� <br /> YNVIRONMENTAL HEALTH PERMIT/SERV#CES <br /> APPUCANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING IF VEHICLE INVOLVED, GIVE <br /> CON rRACTOR AND,OR PUBLIC POOLS,WATER SAMPLING Make <br /> BROKER AND,QR REAL ESTATE INSPECTIONS Lic. No. <br /> irENSE AND,OR POULTRY RANCHES AND KENNELS - <br /> 3TRATION MISCELLANEOUSSERVICES Regist. No <br /> 1. aER . __- <br /> -- <br /> - <br /> Color <br /> Application Date a_�__ Business/Name To Appear On Permit <br /> Type Permit,Service Re ested: - -x f'jAQ�_ } 0rk j0.[" _k-e-VI/e- _ <br /> Z Applicant . � -Lr <br /> + - Address <br /> U - <br /> CL <br /> CL Sic-ra in-n T CA, C291. Business Telephone No. _ _ _ --. . Emergency Telephone No. <br /> a Property Location/A ress�0 ►"-Wr. <br /> aProperty Owner_ ed. .SOL'1 -�� Address - — -- _ <br /> LOperator'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 OCCU 1LTI/ <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> 13 PUBLIC 2 91988 <br /> PUBLIC WATER SYSTEM C] SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO OF PUBLIC SERVED (Connections) ._ <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BAT Ni"�C�! idiF,L HiALTri <br /> `PIS <br /> 5. VECTOR CONTROL El POULTRY 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 /> Water Supply Source _ Animal Waste Disposal Me hod <br /> 6. ,'CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL_ ESTATE <br /> REQUEST Water Well Inspection El 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, d rules--and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X - -- TitleDate <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 EXPLANATIONBILLING <br /> { DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEELESS <br /> S <br /> PRORATION �o — 0.1; - -� <br /> PLUS <br /> PENALTY <br /> OTHER PIF.N/1'.1 <br /> - <br /> - - <br /> OTHER AVS-H�Olvl Lli_ ll�t� L,•: ,i�. ` 7 -7 <br /> --- — - - - --I ----- - <br /> Be ed 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 />