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Applications Will Be `cessed When Submitted Properly Completed. Bce To Sign The Application, <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEERS AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS, HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS, WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Llc. No. <br /> JrENSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> STRATION MISCELLANEOUS SERVICES <br /> 1 . .dER — _ _ — Color <br /> ( Application Date Business/Name To Appear On Permit . . . <br /> Type Permit/Service R quested: -7 <br /> a ACpplica t Na e 2� �`�,.,_ AddressFnT <br /> d �- -�-`-"� Business Telephone No. - � Emergency Telephone No. <br /> aProperty Location/Addffess - <br /> aProperty 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 Supply 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 /> i <br /> Seller Seller Address <br /> f Telephone No. Seller Agent Name <br /> fService 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 /> APPLICANTS SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE EACH El January 1 8 Received By January 37 11 July 1 a Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNTDUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> � py9 I <br /> FEE 6 <br /> ou <br /> N <br /> F' PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ' <br /> eel <br /> v 0 /6 <br /> Received by Dale Recei t No. Permit No. Issuance Dale Mailed Delivered <br /> _ . . . APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE., P.O. Box NO STOCKTON, CA 95201--- <br />