COMPLIANCE INFO_1986 - 1998 - Laserfiche WebLink

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ENVIRONMENTAL HEALTH PERMIT/SERVICt.; ENGINEERS AND OR IF VEHICLE INVOLVED, GIVE APPLICANTS ANDiOR FOOD ESTABLISHMENTS.HOUSING Make CONTRACTOR AND'OR PUBLIC POOLS,WATER SAMPLING & -" -- " BROKER AND/OR REAL ESTATE INSPECTIONS C&Mp Lic. NO. ir'ENSE AND-OR POULTRY RANCHES AND KENNELS /� pr Regist. No. ,TRATION 7 MISCELLANEOUS SERVICES th,RCOS 6 �J "" ----- ---- I. .9ER y3o��0.3 COIOr ----- ---_-._.-._-- Application Date _�I �0 Business/Name To Appear On Permit - FType Permit/Service Requested: - -- -- <Applicant Name - - - - -- _.-. _ ddress _ - Bqsiness Telephone No. -� -'v C 4°4 Emergency Telephone No. -- a Property Location/Address `Property Owner ta/4t.Q Address WC-x 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 ❑ 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 ❑ 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 5. 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 -- - — WaterrSS pply Source --_-------- -- -_ Animal Waste Disposal Method 6. L� CONSULTATION FEEL�_G_-S _ -- - -- -- --- - 7. ❑ PLAN CHECKING FEE --— - - -- ------- ---— -- - 8. 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 accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. APPLICANTS SIGNATURE X -- Title_ Date FOR DEPARTMENT USE ONLY Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 b Received By July 31 - -EXPLANA -—�- - --- REMIT BILLING REMITTANCE $ AMOUNT DUE CHECKED AMOUNT 4 BASE TION DATE DATE REMITTED _lO 70 FEE - LESS PRORATION -- PLUS PENALTY OTHER OTHER S4114,... Received by Dale Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1901 E.HAZELTON AVE.,P.O.Boa 3009 STOCKTON,CA 9520 -�•- -cas i+ a-meet�.^.T'.: ;'�.'A�r.R'� 71�-l ('.k�'��t"i�z�r� i,�` "• -�' i •. �. ;...,;