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Applications Will Blecessed When Submitted Properly Completed. Ire To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR F000 ESTABLISHMENTS,HOUSING <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS <br /> 1r.ENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION �^ MISCELLANEOUS SERVICES C(ORegr___ <br /> t. .dER ii •IJJ h Color <br /> (Application Date1 -a U-qy Business/Name To Appear On Permit _ <br /> u)Type Permit/Service Requested: <br /> A plicant Name 11 C Q��en 1'qd6e `n <br /> --� -�= <br /> aBusinessOTephone No. t _. Emerge y Telephone N� <br /> a — — <br /> i Property Location/Address - C�p� e S (]�, <br /> `Pr6perty Owner UI.S Address — �A�hr`o(J Lf t^a0 <br /> 10perator's Name i=�e's A9_M\1C VC:r Address R <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 /> .ENNEURunways /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 �� a> > - I -AE rJ -1 _q 0 SyNa(` a C S <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. Seller 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 regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 d Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE = REMIT <br /> AMOUNT DUE CHECKED <br /> p�]DATE DATE REMITTED T^ AMOUNT_ <br /> FEE p� 87. 2 90 '3 00 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY PENAL71ES WILL.BE A:'P 1[-D T P,`� +; DUE C A COUNTS 30 <br /> OTHER �RQM b1rT1N—G_D_A'j-L—. <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1.601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 96201 <br />