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' Applications Will Be Pro d When Submitted Property Completed. Be Sur Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> x . <br /> ENGINEERS AND/OR ^ IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR _ ` ` FOOD ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> .Ir'ENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> i. BER -- --- - Color <br /> rAPP <br /> Iicat on Dato—_ siness/Name To <br /> Appear On Permit <br /> I — Bu <br /> wT e Permit/Service Requested: <br /> -- <br /> r YP q <br /> zaAPPli ant Name <br /> Address �� 2 , ���1 T� �t <br /> � L - <br /> I M 1/ <br /> O)5 ld-'D Business Telephone No.16 Emergency Telephone No. <br /> IL <br /> a Property Location/Address <br /> -_'j <br /> V � v <br /> J Property Owner f���Ll.-- I � � _ Address <br /> a <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 E <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 ro <br /> 3. WATER OUALITY ❑ WATER SAMPLE(Bacterial) ❑ CHEMICAL "ice <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER '- <br /> NO. OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH C1SWIMMING POOL 13SPA E] WADING POOL ❑ NATURAL BATHING PLACE <br /> 8. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <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 <br /> 6. ❑ CONSULTATION FEE ,IF i` l l i Tl` I t +' _T`)L t"L y'-3� <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 /> n t Escrow No. <br /> ,Y <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 /> (Z 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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT. <br /> FEE <br /> LESS ''W <br /> PRORATION I <br /> PLUS - <br /> PENALT-y <br /> OTHER p <br /> OTHER <br /> t <br /> Received by Date ..ipt No. Permit No. Issuari,41111111i Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />