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Y <br /> IL Applications Will Be Pr sed When Submitted Properly Completed. Be S o Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERV40E <br /> ENGINEER'S AND/OR INVOLVED, GIVE <br /> CONTRACTOR AND OR �� PUBLIC FOULS,WATER SAMPLING <br /> Lo <br /> APPLICANTS AND/OR FOOD ESTABLISHMENTS.HOUSING <br /> e —. — ---_._....---- - <br /> BROKER AND/OR ; REAL ESTATE INSPECTIONS Ic. N0. _.— <br /> Ir'ENSE AND/OR POULTRY RANCHES AND KENNELS Regist. No <br /> 3TRATION MISCELLANEOUS SERVICES g -- <br /> I. .dER _._..Q /l /Color ----- ---- <br /> Application Date_Sly5 - C f/ Busines /Name o Appear On Permit _�{JC(iL�LZJ�'-�� <br /> FType Permit/Service Requested: /��1/�L� <br /> a Applicant Name Address / _3 <br /> aBusiness Telep one No. --_____—___ Emergency Telephone No. <br /> a Property Location/Ad res - 1�] /_ 7-10 --- <br /> aProperty Owner_ _ [ � Address 1__�_ ! 7`tJ�{ T Q o2 J� - y' <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 ❑ 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 /> F :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. C NSULTATION FEE / <br /> 7. r LAN CHECKING FEE L � <br /> 8. 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. <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 i &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> _ W r�r� AMOUNT <br /> FEE _34L, /J �'�I /-711-- — <br /> LESS C�Le� �/ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No Issu,nce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O. oi 2009 STOCKTON,CA 95201 --- <br />