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Applications Will Be Pro ted When Submitted Properly Completed. Be Su, 'o Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> • <br /> ENGINEER'S AND/OR IT:'VEHI LE{NIR VtD, GIVE <br /> APPLICANT AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING fthrake, - <br /> BQ� 'R AND/OR REAL ESTATE INSPECTIONS Lag., No. <br /> AND/OR POULTRY RANCHES AND KENNELS -A" <br /> yAATION MISCELLANEOUS SERVICES eglSt. No. <br /> f Application Date Business/Na e To Appear O P!r�it <br /> FI Type Permit/Service Requested: `Y G►��f �Q�lr{/ .�+. <br /> uApplicant Nameu�n L4/4-��'�+CGlrlar.ZnC _ Addreess_ ._/?13 2- <br /> &V4.T -*Xj0 64- Bu(,sttyryes�,s,�Telephone OAM!7 �-f_ OD Emergency Telephone No. <br /> 0. <br /> Property Location/A r�e- _�_/_ ��CJ�L`-y�V�`�"fnE-r---j <br /> `Property Ownerl�,L_ J�y[J1 ---- _-- _ Address <br /> L Operator's Name __� /1�� 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 /> 'F.CTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds _ <br /> h-'�ENNEL/RLin ways /Animal Population No. _ - No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method _ <br /> Water Supply Source Animal aste Disposal Methpd _ <br /> 6. -IRICONSULTATION 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 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 &Recerved By July 31 <br /> BILLING REMITTANCE j REMIT <br /> BASE EXPLANATION GATE DATE REMITTED AMOUNT DUE CHECKED <br /> AO AMOUNT <br /> FEE 3 �� L 7/—V 88 ��LL! <br /> LESS �� �� <br /> PRORATION <br /> PLUS <br /> `WPENALTY <br /> OTHER PES,. T' WILL BE APP JEDTO PAST DUE ACCO' <br /> OTHER <br /> Received by Date Receipt No Pennil No Issuance Date Mailed Dehvered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />