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ENGINEER'S AND/OR <br />APPLICANT'S AND/OR <br />CONTRACTOR ,AND/OR <br />BROKER AND/OR <br />ir'ENSE AND/OR <br />3TRATION <br />dER <br />Applications Will Be Prd When Submitted Properly Completed. Be ST . � <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICE <br />FOOD ESTABLISHMENTS, HOUSING <br />PUBLIC POOLS. WATER SAMPLING <br />REAL ESTATE INSPECTIONS <br />POULTRY RANCHES AND KENNELS <br />MISCELLANEOUS SERVICES <br />Sign The Application. <br />IF VEHICLE INVOLVED, GIVE <br />Make ---— --- - <br />Lic. No.------- <br />Regist. No. <br />Color ._ <br />I. . __ --___ --- -- -- - <br />Application Date __J_� ^ o �-- Business ame To pear On Permit ar- <br />Type Permit/Service Requested:___ pp rr <br />Applicant Name �� � - D _Address � L�tn r`c T_0i' S33 f <br />C _ _ Bu iness Teleph n No. _ Emergency Telephone No. <br />J <br />aProperty Location/Address �'__ <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 — ALL APPLICANTS: Total Employees Including Operators .. ---- <br />2. HOUSING VIA p <br />❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY e �C <br />❑ MOBILE HOME PARK/No. of Spaces -2 ONL <br />3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br />❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WA R HAULER <br />NO. OF PUBLIC SERVED (Connections) <br />4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WING POOL 11NATURAL BATHING PLACE T <br />5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Bird - p Ay <br />CiEIV Sp <br />,ENNEL/Runways _ ._-- /Animal Population No. No. of Confining Cages EiE <br />Sewage Disposal Method n <br />Solid Waste Disposal Method Nov <br />Water Supply Source__ <br />Animal Waste Disposal Method <br />AUTH <br />6. CONSULTATION FEE t an h OeL T' <br />7. ❑ PLAN CHECKING FEE o�p�SERV <br />B. REAL ESTATE <br />REQUEST: Water Well Inspection 13 Sample[] Title Company <br />C-:) <br />Sewage System Inspection ❑ Address Tele. No. C­� <br />Escrow No. I <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 Joaquip Counl`X <br />ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br />' Q <br />APPLICANT'S SIGNATURE X U Title 4tin,42466e <br />FOR DiPARTMENT USE ONLY <br />I iwuT fl PFG cITF ❑ FACH ❑ January 1 & Received By January 31 ❑ July 1 & Received By July 31 <br />17_ //- C/-;�p`' 1111/; � <br />c ed by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br />APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE., P.O. Box 2008 STOCKTON, CA <br />i <br />REMIT <br />BASE <br />EXPLANATION BILLING <br />REMITTANCE <br />$ AMOUNT DUE <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT _ <br />3° _hou <br />�j <br />FEE <br />, <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />PC Vi/Al_ �i � <br />Yhv IL.� - C^ <br />°' n <br />FR0M <br />BILLING ATE. TWE <br />ACco <br />TC <br />1d 33 <br />OTHER <br />OTHER <br />17_ //- C/-;�p`' 1111/; � <br />c ed by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br />APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE., P.O. Box 2008 STOCKTON, CA <br />i <br />