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.. Applications WIII Be Prt ;ad When Submitted Properly Completed. Be St 3 Sign The Application. <br /> APPLICATION <br /> ' ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGI^,:ER'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 /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> IrENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> I. .BER Q Color .------------------------- -- <br /> rApplication Date __ �L�w�__ Business/Name To Appear On Permit <br /> oType Permit/Service equested: _— /� � <br /> =A Iicant Name _._ W -�^�-`t wNSu L, $ZJD - ZT�+ f to <br /> OF pP � .------ -�� ---� -- Address -- ---`- --ST-�11�I <br /> _Q. Lqg�___(./� q�(0�.� Bu IF Telephone No. _._-___.__...—_____—____ Emergency Telephone No. <br /> CL <br /> Property Location/Address � CABG <br /> --- <br /> aProperty Owner 6_tu- I N - -__ 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 ❑ 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 /> T :ENNEL/Runways -_-___ _ /Animal Population No. _ No. of Confining Cages_ <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method — <br /> Water Supply Source �_ Animal Wase Disposal Method <br /> 6. CONSULTATION FEE Ql-iU�_P SCILL T11"Tldk.J ri2�- KID 61 L 3: <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 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: C1 ANNUALLY ❑ PER UNIT 1-1PERSITE El EACH C3 January 1 &Received By J nuary 31 ❑ J ly 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION AMOUNT D E CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE lr O <br /> z <br /> LESS <br /> PRORATION - .. <br /> PLUS J 1 <br /> PENALTY <br /> OTHER r 6-2 <br /> OTHER --� <br /> 1,o Li <br /> Receive Date Receipt No Perini[No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO. ENVIRONMENTAL HEATH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P O.Box 2009 STOCKTON.CA 95201 <br />