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Applications Will Be P Assed When Submitted Properly Completed. Be c -To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'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 /> 71<ER AND/OR REAL ESTATE INSPECTIONS Lic. No. _— <br /> FNSE AND/OR Unit III POULTRY RANCHES AND KENNELS Regist. No. <br /> ;TRATION MISCELLANEOUS SERVICES g __----- <br /> .dER ------------- -- Color — <br /> Application Date_— _. Business/Name To Appear On Permit — <br /> ,nType Permit/Service Requested: --- <br /> `Applicant Name SiebOlt COTe• Address aLO American Street, <br /> Stockton CA 95202 Business Telephone No. Emergency Telephone No. <br /> a Property Location/Address 800 E. Main Street <br /> a <br /> Property Owner _ -- Address <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 Q 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 PPLACYE C3PUBLIC WATER SYSTEM ElSURFACE WATER SUPPLY 11WATER HAULERONO. OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH C1SWIMMING POOL ❑',SPA ❑ WADING POOL ❑ NATU L BA IN <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> r :ENNEL/Runways _ /Animal Population No. t'° No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply 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 I have prepared this application and that the work will bip done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local He District. <br /> APPLICANT'S SIGNATURE X Title ` Date <br /> a <br /> FOR DEPARTMENT USE ONLY '+ <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> B S <br /> BASE :[EXPLANATION REMITTANCE 1190 DATE REMITTED AMOUNT DUE AMOUNT <br /> D <br /> FEE $35-00 Sail Samlidig for t <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Rb _pt No. Permit No IssuanL. _.ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo:2009 STOCKTON,CA 95201 <br />