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Applications Will E messed When Submitted Properly Completed. F ,ire To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <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 /> ir'E_NSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> I. .r3ER Color <br /> [Application Date T- _-�-� Business/Name To Ap ar Py Perrni� <br /> Type Permit/Service,Re`quvested: �•fl'7�� --- <br /> Applican Name —+:r2 .- `�0 � __ Addrescs��- <br /> j Bus Hess Telephone No. �Z� = O� E ergencyCTel phone No <br /> IL <br /> Property Location/Addr I <br /> aProperty Owner _K 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 /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. 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 /> Water Supply Source Animal Waste D posal ethod Of <br /> 6. .CONSULTATION FEE ��1��Y HA2 !D <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 �II11 CC wwll <br /> Fee IS Due: 11 ANNUALLY El PER UNIT 11 PER SITE El EACH ❑ JarRAYHlue®a>ryTanuary 31 ❑ July 1 &Received By July 31 <br /> E t)(E D REMIT <br /> BASE EXPLANATION BILLING REMITTAI AMOUNT DUE CHECKED <br /> �/�i DATE DATE REMITTED AMOUNT <br /> FEE /O5 •V(J Ai0' JUL 89 <br /> LESS <br /> PRORATION <br /> PLUS PE IT SERVICE <br /> PENALTY <br /> OTHER p NALTiES WIL BE APPLIED O ` <br /> 7 �IV <br /> OTHER <br /> Received by � Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952011 <br />