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. f 1 Applications WIII Be Pn ed When Submitted Properly Completed. Be St Sign The Application. <br /> L'.. APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR HI �Pj GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Ma <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> _)KER AND/OR REAL ESTATE INSPECTIONS <br /> NSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> I. .BER ._ - _Q Color <br /> f Application Date—Z-l�V� Business/Name To Appear On Permit <br /> HType Permit/ServiceI'�equested: <br /> `Applicant Name __IljmwN_Cct. t ` bi suL-N 75 Address_ D��_Z '3ulTl-- <br /> Q1D <br /> Bu mess Telephone No. _ Emergency Telephone No. <br /> Property Location/Address — � � G _ <br /> Property Owner— V Q6 L—�_541M hJ1TL _ 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 /> RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 'ECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> :ENNEL/Runways _ /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source _ _ _ Animal Was Disposal Method <br /> 6. CONSULTATION FEE r I ►SL( SU�7�I"T1 Qhs �I 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: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 S Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> _ AMOUNT <br /> FEE �,O — — <br /> LESS <br /> r <br /> PRORATION _ _ ENA_LTIE�`.'`.��' 1'~ •��1./�J•T\7 t..>"I <br /> PLUS ,/ r:i.' ' <br /> PENALTY o <br /> R <br /> OTHER 1 52. -2116q� <br /> OTHER <br /> Received by Date Receipt No Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN AL1.COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZF.LTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />