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Applications Will Be Prr^-tsed When Submitted Properly Completed. Be Su— To Sign The Application. <br /> APPLICATION Unit III <br /> ..r4VIRONMENTAL HEALTH PERMIT/SERViCES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S ANO/OR FOOD ESTABLISHMENTS.HOUSING Make <br /> CT..ITRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING <br /> BACKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> .IrFNSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TRATION MISCELLANEOUS SERVICES g <br /> I J .aER _. Color <br /> - <br /> rApplication Date �c�Z�/�n—D Business/Name To Appear On Permit <br /> ,,Type Permit/Service Requested: <br /> uApplicant Nam2 Ll�O Address t7 �v'�riC <br /> a Business Telephone No. Emergency Telephone No. <br /> a Property Location/Address (7� <br /> `Property Owner Address✓moo�o Address . l'�G *,1 <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 V OR <br /> ❑ VENDING MACHINES/No. of 1:1 MOBILE FOOD PREP. UNIT C3VEN G OR <br /> /_' <br /> 1:1 FOOD CROP HARVESTING/No. of Field Employees n d1p� 06en� A-- <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. 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 C3 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, and rules and regulations of the San Joaquin Local Health District. <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 b Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT_ <br /> FEE Q� - 11130190 Q 0 <br /> LESS <br /> PRORATION •-• ... <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER i �Il::,j <br /> Received by Date Rece a. Permit No Issuance. Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />