Laserfiche WebLink
Applications Will Be Pr sed When Submitted Properly Completed Be $I <br /> o Sign The Application <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES IF VEHICLE INVOLVED,GIVE <br /> ENGINEERS AND/OR FOOD ESTABLISHMENTS HOUSING Make <br /> APPLICANT S AND/OR PUBLIC POOLS.WATER SAMPLING <br /> CONTRACTOR AND/OR REAL ESTATE INSPECTIONS Ltc No <br /> BROKER AND/OR POULTRY RANCHES AND KENNELS Regist No <br /> O8SE AND/OR MISCELLANEOUS SERVICES <br /> TRATION Color <br /> ER <br /> �zBusiness/Name To Appear On Permit <br /> f Application Date <br /> ,*Type Permit/Service Requested QU -10 <br /> r,.,�� <br /> i Applicant Name <br /> kl���>� ` Address ��`�� �usine s Park Dr�v <br /> O Gra Business Telephone No I(I °— = Emergency Telephone No <br /> Z err roc 67 <br /> i Property Location/Addres's Ur f <br /> dProperty Owner Address <br /> Address <br /> Operator s Name <br /> 1 FOOD ESTABLISHMENTS Total Building Sq Footage Restaurant, Maximum Seating Capacity <br /> 11 RESTAURANT 13 FOOD MARKET RETAIL 11 FOOD MARKET WHOLESALE MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY 11 ICE PLANT 11 BAKERY <br /> ❑ ROADSIDE FOOD STAND El LIQUOR STORE ❑ BAR 13 ITINERANT RESTAURANT <br /> 13 CONFECTIONARY STORE El FOOD SALVAGER ❑ FOOD DEMONSTRATION 13 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 ❑ CERTIFICATE OF OCCUPANIFECEIVEID <br /> AYM ENT <br /> ❑ HOTEL/MOTEL/No of Units <br /> ❑ MOBILE HOME PARK/No of Spaces <br /> 3 WATER QUALITY El WATER SAMPLE (Bacterial) 13 CHEMICAL JUL 2 5 1�oo <br /> El PUBLIC WATER SYSTEM 11 SURFACE WATER SUPPLY © WATER HAULER <br /> NO OF PUBLIC SERVED (Connections) tl��,� ��usENTAL HEALTH <br /> 4 RECREATIONAL HEALTH El SWIMMING POOL 13 SPA E-] WADINGPOOL 11 NATURAL BAT9M pRMi�rSERVI�ES <br /> VECTOR 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 /> Animal aste Disposal Method <br /> Water Supply Source r , <br /> 6 CK CONSULTATION FEEr <br /> '4 r <br /> 7 13 PLAN CHECKING FEE 2Q$ G-rc�N �rK� ���1 aGy [ctfr Ol'Yth � <br /> 8 REAL ESTATE <br /> REQUEST Water Well Inspection[] Sample 13 Title Company Tele No <br /> Sewage System Inspection ❑ Address <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 /> APPLICANTS 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 &ReceiveRdB July 31 <br /> BASE EXPLANATION IT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> A PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7� at Receipt No Permit No Issuance Date Mailed Delivered <br /> Ived by <br /> 1801 E HAZELTON AVE P O Bol 2009 STOCKTON CA 952 <br /> APPLICANT—RE URN ALL COPIES TO ENVIRONMENTAL HEALTH PERMIT/SERVICES — — <br />