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ENVIRONMENTAL HEALTH PERMIT/SERVICE- <br /> ENGINEER S <br /> ERMIT/SERVICEENGINEERS AND OR IF VEHICLE INVOLVED, GIVE 1 <br /> APPLICANT S ANDIOR f000 ESTABLISHMENTS,HOUSING t Make -__________._ <br /> CONTRACTOR AND O PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND OR REAL ESTATE INSPECTIONS Lic NO. - <br /> irENSE AND OR POULTRY RANCHES AND KENNELS Regist. No <br /> 3TRATION MISCELLANEOUS SERVICES g - j <br /> i. dER Color --------- --- -- <br /> Application Date B slness/Name To Appear-On Pgrmit -------------- <br /> oType Permit/Service Requested: �/— <br /> <Applicant Name A?19h 6 �� , I /-�C Address 2-3 3_ � S SG <br /> �j n� Gg-gYsBj B _,y ess Teleph ne No. __ __ __ -._.-_ ___ _ Emergency Telephone No. <br /> Property Location/Address - <br /> -J'Property Owner Address _— -- - --- <br /> (Operator's Name ___,r _- ---- -- Address ----- - <br /> 1. FOOD ESTABLISHME4fS 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 --- -- _--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 /> S. 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 Supply Source __ Animal Waste sposal Me hod _ <br /> 6. 9 CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE <br /> B. REAL ESTATE <br /> REQUEST Water Well Inspection C1 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 <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 6 Received By January 31 ❑ July 1 h Received By July 31 <br /> -- — - ---- --- REMIT <br /> BASE E%PLANATIONT BILLING REMITTANCE I $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED _ AMOUNT <br /> FEE --_ � Di✓ /[�K/�j77V' ___— __ _-- _— <br /> LESS <br /> PLUS <br /> PENALTY _ <br /> OTHER 57Z,5 8/17/$$ U <br /> OTHER <br /> Received 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.Sam 2009 STOCKTON,CA 95201 <br />