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Applications Will Be Pror,ssed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SEMES <br /> ENGINEER'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 /> i(-ENSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TRATION MISCELLANEOUS SERVICES g - <br /> i. 8ER Color <br /> Application <br /> Application Date �" Business/Name To Appear On Permit �' 7('Lrfl�6 <br /> o,Type Permit/Service Requested: I� 1 <br /> a Applicant Name ' yL�_ � ! L �:- Address r �Tf eE�l��•=� Olrr � <br /> ('f1L1riL::rfl /:� Busines Telephone Emergency Telephone No. <br /> a Property Location/Address O L(J�r'0� �' ^. ��,�r� �'�. ✓�� J� <br /> `Property Owner � � Address . y <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 _- PAY&IC <br /> 2. HOUSING RECRj16v&D <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> 1:1MOBILE HOME PARK/No. of Spaces JU/'E�( <br /> 2, o f <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER -MVIRONM <br /> NO OF PUBLIC SERVED (Connections) _ - - PERM <br /> F I / ��� �EA�rH <br /> 4. RECREATIONAL HEALTH 1:1 SWIMMING POOL 1:1 SPA El WADING POOL 11 NATURAL BATHING PLA(/ CES <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 <br /> Supply Source Animal Waste Disposal Method <br /> 6. /6l CONSULTATION FEE � ( � 1� � A✓� � 7Y� JI '91 46 <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 Fufes and regul doof the Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X v Title � ��� Date r �� <br /> OIX FOR DEPARTMENT USE ONLY <br /> Fee IS Due: C3 ANNUALLY El PER UNIT 1:1 PER SITE El EACH ❑ January 1 &Received By January 31 C1 July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY _-- <br /> OTHER <br /> OTHER � <br /> R ei d by Date Receipt No. Permit No Issuance Date Mailed Delivene <br /> PLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />