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ti T� <br /> Applications Will Be Pro -?d When Submitted Properly Completed. Be Su Sign The Application. <br /> APPLICATION <br /> �-E,,NVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR G�1V 1Ir° IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'$AND/OR FOOD ESTABLISHMENTS, HOUSING Make <br /> CONtRACTOR AND/OR PUBLIC POOLS, WATER SAMPLING — --- <br /> BROKER AND/OR /,- J 1,3-1 REAL ESTATE INSPECTIONS LIC. NO. <br /> irENSE AND/OR l POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Reglst. No.— __—__--.- <br /> I. .aER ------------- ---- ENTAD- HF"� Color _ <br /> ^�r <br /> rApplication Date PJ L f/ Busines /Name o Appear On Permit — -- <br /> F Type Permit/Service Requested: <br /> `Applicant Name , �h! Address 17 (/e—111 <br /> Q= 049 <br /> _ Business Telep ne No._ -- _ Emergency Telephone No. <br /> a Property Location/A re s <br /> Property Owner _ Address �� d� TU 02 3 , <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. <br /> perators ___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 <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 BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds — <br /> .ENNEL/Runways _ /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water ply Source _ Animal Waste Disposal Method <br /> 6. QNSULTATION FEE <br /> 7. LAN CHECKING FEE l�I s 142� <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample El 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. <br /> APPLICANT'S SIGNATURE X _ _ Title Date _ <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 /> AM NT_ <br /> FEE J ov_ I <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date P No Permit No Issuan to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRO,,_4NTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 S?OCKTON,CA 95201--- <br />