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bs <br /> ' <br /> Applications Will Be Ped When Submitted Properly CompleteeS o Sign The Appliestion. <br /> ` APPLICATION W-- <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S ANDIOR FOOD ESTABLISHMENTS,HOUSING - <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER'AND/OR REAL ESTATE INSPECTIONS LIC. / <br /> IrENSE AND/OR POULTRY RANCHES AND KENNELS ISt. NO. <br /> 3TRATION MISCELLANEOUS SERVICES I ,.- g — -- <br /> i. BER _ —__- _—_-- 01or - <br /> Application Date 0 76 •. 1! 0 r E' � 1 r i�'1 be poi <br /> -- r S'ysines Name To � pear On Pe mit. t <br /> ,*Type Permit/Service Requested: n l CA r k V S n G 100 <br /> aApplicant Name Q ��' P '� — Address ' r I 5 J �� <br /> j � 13 iness T leph ne No. Emergency Telephone No. <br /> a Property Location/Address ^ r0!`� t <br /> -ji Property Owner _ _ _—_ Address <br /> Operator's Name Address <br /> 1. FOOD ESTABLI "IDENTS_ 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 E �1rJ <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 N <br /> r :ENNEL/Runways _ /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Disposal Method t <br /> 6. ❑ CONSULTATION FEE n �� <br /> - it <br /> 7. ❑ PLAN CHECKING FEE 4.3 <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ Sample Title Company <br /> Sewage System Inspection ❑ Address Tele. No. X, <br /> Escrow No. — <br /> Seller Seller Address <br /> Telephone No.— Seller Agent Name r _ d <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 _61.r,4 c./ Date41 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT_ <br /> FEE "ux + � /1Qi� 1V �1��" � d • "l! s <br /> LESS <br /> PRORATION <br /> r" gal <br /> PLUS z y, f tet. tlri <br /> PENALTY <br /> OTHER <br /> OTHER '' <br /> Received by Date l0eipt No. Permit No. issqWuate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />