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Applicattons Will Be Proo- 'sed When Submitted Properly Completed. Be Suro To Sign The Application. <br /> IWA.. APPLICATION .WV <br /> + ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'SAND/OR FOOD ESTABLISHMENTS, ST471 VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND OR PUBLIC POOLS,WATER SAMPLING p pAPPLICANT'S AND/OR '`� 1V fake <br /> BROKER AND/OR REAL ESTATE INSPECTIONS ,e r'S Lic. No. ---_ <br /> IrENSE AND/OR POULTRY RANCHES AND KENNELS '}�gt. No. <br /> 3TRATION MISCELLANEOUS SERVICES 14 ��;'�` g .=Color � <br /> I. .BER k \� - <br /> Business/Name To A pear On Permit <br /> Application Date �- �'eq p <br /> ,AType Permit/Service Requested: ---- <br /> z A licant Name617,c� d �n] tvV L kb 40k7�Z-. --- Address <br /> _! uslness Telephone I _ Emergency Telephone No. <br /> Ste— �,- _ - 9 Y P <br /> I�Property Location/Address <br /> aProperty Owner -_PCL(!P �' _ _-- 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 - 7��Animal Waste osal Method <br /> 6. CONSULTATION FEE U(oST SLLLI`ft L� Obgye � _ <br /> 1 Ll <br /> 7. PLAN CHECKING FEE <br /> 8. REAL ESTATE Cl <br /> REQUEST: Water Well Inspection Sample❑ Title Company --- <br /> Sewage <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 <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 $BASE EXPLANATION n nl TT1F-', T T AMOUNT DUE AMD <br /> OUNT <br /> _ _ <br /> FEE - - .,,� 3, s DAYS FROM BILLING DATE. _ <br /> LESS � <br /> PRORATION ' -36, <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER �61 , -1114:1. 7 <br /> c ed 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 />