Laserfiche WebLink
mppncauons wm tierrocetaseaWnenSubmitted Properly Completed. Be Surr To Sign The Application. <br /> APPLICATION <br /> 6�lIR0NMENTAL HEALTH PERMIT/SERVI�S P <br /> ENGIN�q NDiOR <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING R ENVOLVED,GIVE <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING <br /> ED BROKER AND/OR REAL ESTATE INSPECTIONS <br /> IrENSE AND/OR POULTRY RANCHES AND KENNELS LIC. NO. <br /> iTRATION �n. <br /> I. .dEp <br /> MISCELLANEOUS SERVICES �U�Regist.JY;3. ^ <br /> W Color <br /> ENVIRON F <br /> Application Date O Business/Name To A nn SAL H T <br /> Appear On Permit -4z,., t <br /> FType Permit/Service Requ{�s�ed: .�+ f L/ 1 � <br /> nApplicant Name + o Address P0. &A <br /> IL usiness Telephone No,4/-S;J 677&"-„/ ,.._ Emergency Telephone No. <br /> IL Property Location/Address lk'�Akg AW <br /> Property Owner—,W/4iJ�� Address p0 <br /> Operator's Name00” IS , <br /> 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 V .Soj,1jVov-,J <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 /> r :ENNEL/Runways /Animal Population NO. No. of Confining Cages <br /> Sewage Disposal Method ' <br /> Solid Waste Disposal Method <br /> Water S oy Source _ Animal Waste Disposal Method <br /> 4 <br /> 6. CONSULTATION FEE u av5 c 5 <br /> T. ❑ PLAN CHECKING FEE x <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,an rules d re ns of the San Joaquin Local Health District, <br /> APPLICANT'S SIGNATURTitle >1.�-T Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee I9 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1&Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLINDATEG P A I N T REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE � <br /> LESS AUGPRORATION U <br /> PLUS <br /> PENALTY ENViRn <br /> OTHER PER SfRU rH <br /> OTHER <br /> Received by Date Receipt No. Per No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 4009 STOCKTON.CA 9520 <br /> f� K • <br />