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r Applications Will Be Prc sed When Submitted Properly Completed. Be St,- To Sign The Application. <br /> ` 1%W APPLICATION 1. <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEERS AND OR IF VEHICLE INVOLVED,GIVE <br /> APPLICANTS AND,OR FOOD ESTABLISHMENTS,HOUSING Make - - <br /> CONTRACTOR AND OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER ANDS OR REAL ESTATE INSPECTIONS Lic- No. - <br /> ,r'ENSE AND,OR POULTRY RANCHES AND KENNELS Regist- No. <br /> 3TRATION MISCELLANEOUS SERVICES <br /> Color <br /> .BER ... <br /> Application Date Business/Narrjft7ToAQpe'ar/On Pt_�®` <br /> o,Type Permlt:Service Requested: 77 <br /> a Applicant Name ,57---5 Address <br /> iness Tele hone No. <br /> J �1_ Cp`�/ _�/_ __ Emergency Telephone No. --.-- <br /> aProperty Location/A dldre s 11)���-- �( - - —- --- <br /> �Property Owner C - Address ��fQ __-- a41�-clef- <br /> a <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 /> r :ENNEL/Runways /Animal Population No. _ No. of Confining Cages <br /> Sewage Disposal Method --__- <br /> Solid Waste Disposal Method -- - -- - --- ----- - — - - <br /> Wateerr Supply Source __ _ Animl Waste Dispo I Method _ <br /> 6. ;l CONSULTATION FEEJ� <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. MENT <br /> L► <br /> Seller ______ Seller Address - <br /> Telephone No. ____ Seller Agent Name Ain - <br /> Service Request For Date - <br /> I hereby certify that I have prepared this application and that the work will be $614� ( ¢�rage with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health Distp��MIT F4 L HEAL7 <br /> /SERWCE'S H <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 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE REMITTED <br /> + 13"1_. - . . ._ _ _ ��.. .- AMOUNT <br /> FEF: ----- <br /> ESS �^ z <br /> PRORATION + _ _/YYJ. J�i�J� i ------- —`- -----_..- --- -- --- <br /> PLUS I <br /> PENALTY <br /> Pq1N'l�' <br /> OiHFR PAS- F CCOUNTS -- - - <br /> f t! "O 0_ <br /> L1fFF,J r it�Jt"�-t�.I:.Y�t'�7 j✓'TT= _.. .. ( _— .__ _ Y�CC <br /> OTHER <br /> Red by Date Receipt No Permit No Issuance Date Mailed Delivered <br /> PL <br /> ICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA 95201 <br />