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S:f - <br /> Applleations Will Be Pr- sed When Submitted Properly Completed. Be SI To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S ANO/OR FOOD ESTABLISHMENTS.HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOL&WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. NO. <br /> InENSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TRAT1ON MISCELLANEOUS SERVICES <br /> I. .aER Color <br /> c'7 <br /> (Application Date Business/Name To Appear On Permit - <br /> ,AType Permit/Service d-1. <br /> uApplicant Name�/d � � Address< �� - •, � �1 Al_ t _ <br /> d � Business TelepLh�olnne Na. 1 �s Emergency Telephone No. <br /> a Property Location/Address - <br /> aProperty Owner(::::, Address <br /> -Operator's Name /� _ _ S 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�pply Source Animal Wpste i posal Method <br /> 6. LO CONSULTATION FEE <br /> 7, ❑ .PLAN CHECKING FEE <br /> S. REAL ESTATE <br /> REQUEST: Water Well Inspection Sample[] Title Company -. I <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 th' _appIiC tion and that the work will be done in accordance with San Joaquin County <br /> ordinances, state la s, and =1esti a the San Joaquin Local Health District. <br /> r ` <br /> APPLICANT'S SIGNATURE X Title •A�4,0 Si Date 5/ <br /> FOR DEPARTMENT-USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT © PER SITE . ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 iL Received By July 31 <br /> BILLING REMITTANCE S REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE CXD <br /> LESS C L <br /> PRORATION 00 �� .t��� <br /> PLUS u` <br /> PENALTY <br /> OTHER - ..r " <br /> OTHER <br /> I <br /> o . cpo <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE.,,P.O.Box 2009 STOCKTON,CA 95291 J <br />