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.r. <br /> Applications Will Be Prot :d When Submitted Properly Completed. Be Sur i Sign The Application. <br /> v.. APPLICATION vlll�/ <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'rAND/OR IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make .— <br /> CONTRACTOR <br /> ake .CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> Ir'ENSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TRATION MISCELLANEOUS SERVICES - --- --- <br /> I. .8ER - --- - Collor <br /> jr' Appear On Permit / IC+ri✓�✓y -�!__K _1 / _ `+ <br /> Application Date.. - Business/Name To A - <br /> u,Type Permit/Service Requested: L4 - -e rLe,&,- <br /> zApplicant Name .? - _ ,ras!�rr�•'ter _ Address <br /> � �-� <br /> Business <br /> t` Telephone No.— -_—_ Emergency Telephone No. _ <br /> ,,Property Location/Address -1' Rt'r1 _f `tl --�-�+ -- <br /> aProperty Owner t s` ?«�n✓ -_ <>� l� �� !\--._ Address _ /YDS tN C- r,_r 1 <br /> ,_Operator's Name Address - >AM j' <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 Disposal Method <br /> 6. P CONSULTATION FEE'" ;5�~� <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 regula Ions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X /�_-� � __-_- Title /T_ -�'J ---- <br /> d1Pt/,r 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 /> BILLING REMITTANCE y REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS i <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> LReceived by Date _ Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo:2009 STOCKTON,CA 95201 <br />