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Applications WIII Be Processed When Submitted Properly Completed. Be SI-I To Sign The Application. <br /> APPLICATION <br /> �_y <br /> ENGINEER'S AND/OR �VIRONMENTAL HEALTH PERMIT/SERV CES <br /> APPLICANT'S AND/OR <br /> CONTRACTOR AND/OR FOODESTABLISHMENTS,HOUSING IF VEHICLE INVOLVED,GIVE <br /> BROKER AND/OR PUBLIC POOLS WATER SAMPLING Make <br /> IrENSE AND/OR REAL ESTATE INSPECTIONS - - -- <br /> 3TRATION POULTRY RANCHES AND KENNELS Lic. No. -- <br /> I. .BER _-_ MISCELLANEOUS SERVICES Regist. No. <br /> Color <br /> [Application pate_ lM awl 1 15 Business/Name To A C,'r <br /> FType Permit/Service Requested. I?e r , Appear On Permit <br /> � <br /> 'Applicant Name _ L�cL,.. -f rJ,-„.,. �wc, . G✓e- /._ _�Address . If 10 n1�,�,., - <br /> -- Business Telephone No.— E f f j t� / Emergency Telephone No <br /> `a Property Location/Address��I�r. �i I �- -GL .� tf r,� �/ c,t. -- _ <br /> a Property Owner fes+ �_ 57 _ �f c�-Lr �A <br /> L�— -- <br /> Address C <br /> -[Operatoi s Name G. <br /> Address <br /> 1. FOOD ESTABLISHMENTS <br /> 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 <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR 0 ITINERANT RES <br /> ❑ BAKERY <br /> ElCONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION 11 FOOD VENDOR TAURANT <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 /> r :ENNEL/Runways /Animal Population No. _ _._ _-_ <br /> Sewage Disposal Method No. of Confining Cages ----- <br /> Solid Waste Disposal Method _ ---- -- -- - — <br /> Water upply Source Animal Waste Disposal Method <br /> 6. CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE -- <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 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules andel regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE Title G°`�` �/�� Date.. <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 S Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <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 Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bor Mail STOCKTON,CA 95201 <br />