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Applications Will Be Process (hen Submitted Properly Completed. Be Sure Tr 'n The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANTPAYMENT FOOD ESTABLISHMENTS,HOUSING'S AND/OR Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER RECEIVED REAL ESTATE INSPECTIONS SAMPLING t f �Ulq� Lic. NO. <br /> BROKER AND/OR Ms' C M A --.--. <br /> IrFSTRASE TIONOR APR 2 6 19$9 MISCELLANEOUS SERVICES ENNELS ��O`V_ 1 Regist. No. <br /> i. .BER SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> Application Date F1�V{RONMENTAL-H€A:.TH lodifrl�J/Name To Appear On Permit <br /> Type Permit/Service Reques ed: r�' �S I <br /> <Applicant Name <br /> _ �`�,�,p�C -__ �/5 �"tS_ .—.. dress �� ��� r1✓� <br /> _C t* _. — Business Telephone No. z�Z9a� Emergency Telephone No. <br /> a <br /> a Property Location/Address <br /> Property Owner_____ __. — 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 /> r :ENNEL/Runways __ /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water SS�Source Animal Waste Disposal Method <br /> 6. CONSULTATION FEE <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. — ___— Seiler 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 reRilations <br /> Loff the San Joaquin Local Heallth District. <br /> APPLICANT'S SIGNATURE X6�4L 1� _ Title V" Date `. <br /> Of <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 Cl July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE 4/17/90 .7 �� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <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.Box 2009 STOCKTON,CA 95201 - <br />