COMPLIANCE INFO_1986-1989 - Laserfiche WebLink

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Applications Will Be Pr When Submitted Properly Completed. Be S Sign The Application. APPLICATION ENVIRONMENTAL HEALTH PERMIT/SERVICE q ENGINEER'S AND:OR a F,, ICLE INVOLVED, GIVE APPLICANTS AND/OR FOOD ESTABLISHMENTS.HOUSING CONTRACTOR ANO%OR PUBLIC POOLS.WATER SAMPLING OKER AND/OR REAL ESTATE INSPECTIONS ENSE AND/OR , POULTRY RANCHES AND KENNELS o 3TRATION MISCELLANEOUS SERVICES 1, BER COIOf Application Date___.� ^ ". o ----- Business ame To pear On Permit Sf l a r pe ' 4 rr"y- be PO Type Permit/Service Requested ----Army- - A/1 k 5�L C+1 O In _ L0. 1 <Applicant Name _..,h a Y�_,01e /'[.��1?'►-_- Def t- Address R O�VI L5_�,3� ___- _. -____ /___ _ _ Bu iness Telephgne No.- _- Emergency Telephone No. IL /� �" p Tf a Property Location/Address - 11Q T'l-L - �-�..__�-� -l� /'Qj j._`. !`t - -- --- ---- - ---- ---- aProperty Owner - ____-____ Address 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 ❑ P-UBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER NO. OF PUBLIC SERVED (Connections) -- RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds __.-__ ________..___ _ .ENNEL/Runways -- ______._____. /Animal Population No. --_-_-____._______-_._ No.of Confining Cages Sewage Disposal Method ----------- ------------- ---- -------------------- - ----------- Solid Waste Disposal Method_ - ---- ------------------- - Water Supply Source __-_. ,_ Animal Waste Disposal Method 6. CONSULTATION FEE _ L IOt�--- -__-----___-- ----.--_-__---- -- 7. ❑ PLAN CHECKING FEE --- - 8. REAL ESTATE REQUEST: Water Well Inspection❑ Sample O 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. APPLICANT'S 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 &Received By July 31 ---- ----- -- REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE QQ DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER J-------------- Received by Date Receipt No Permit No Issuance Date Mailed Delivered �'i' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201