COMPLIANCE INFO_1985-2005 - Laserfiche WebLink

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It ENGINEER'S AND/OR APPLICANT'S AND/OR CONTRACTOR AND/OR BROKER ANO/Ok IrF_NSE AND/OR 3TRATION I. .8ER ----- ---- ------ APPLICATION XONMENTAL HEALTH PERMIT/SERVIC FOOO ESTABLISHMENTS. MOUSING PUBLIC POOLS. (MATER SAMPLING REAL ESTATE INSPECTIONS POULTRY RANCHES ANO KENNELS MISCELLANEOUS SERVICES IF VEHICLE INVOLVED, GIVE Make ---- Lic. No.-.----- Regist. No. Color -_-__—_-- [Application Date - t-92 —_—__ Business/Name To Appear On Permit 5.5S101JS-1'�� aType Permit/Service Requested: Applicant Name s�>Ef7SIC*21S EL)& tu£at 17GWC -- _ Add�res(s��P -- / �L [�C�7rTYLpt�4 �1`2�Z_ _ Business Telephone No.lS� --- sir Telephone Hol 2"4 ILProperty Location/Address dProperty Owner _W. 12. STS%_ -- - - Address2—-`--«` [Operator's Name —_-- ____ -- _- Address --_---------.--_-_-- _ -------- 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR ❑ VENDING MACHINES/No. of - _____ ❑ MOBILE FOOD PREP. UNIT Q VENDING VEHICLE ❑ FOOD CROP HARVESTING/No. of Field Employees ALL APPLICANTS: Total Employees Including Operators 2. HOUSING ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY ❑ MOBILE HOME PARK/No. of Spaces 3. WATER QUALITY I ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER NO OF PUBLIC SERVED (Connections) - - -- -- --- - - 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds -- - - r :ENNEL/Runways - /Animal Population No. - -__ _ - _ _ __- No. of Confining Cages - Sewage Disposal Method_ -- Solid Waste Disposal Method -- Water Supply Source _- .. Animal Waste Disposal Method__ - 6. X CONSULTATION FEE ��Q-- 7. ❑ PLAN CHECKING FEE -- -- -- -- B. REAL ESTATE REQUEST Water Well Inspection Sample❑ Title Company -- Sewage System Inspection ❑ Address Tele. No Escrow No. Seller Seller Address - - ----- - --- - Telephone No Seller Agent Name Service Request For Date I hereby certify that I have prepared this application and that the work will be done in acconcaquin my ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. APPLICANT'S SIGNATURE X Title Date FOR DEPARTMENT USE ONLY Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & Received By January 31 C3 July 1 d Received By July 31 _ REMIT BASE EXPLANATION BILLING REMITTANCE i AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE Received by Date -- -Receipt No Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE., P.O. Boa 2009 STOCKTON, CA 9S;