Laserfiche WebLink
MW <br /> Applications Will Be,,iad When Submitted Properly Completed. Be SNY <br /> Sign The Application. <br /> APPLICATION is I NTENVIRONMENTAL HEALTH PERMI `t�/e�, <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING ..��},ake <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING APR ii �' <br /> BROKER AND/OR REAL ESTATE INSPECTIONS r R "LfC. N0. <br /> ND/OR POULTRY RANCHES AND KENNELS Re <br /> ir.ENSE AND/OR <br /> MISCELLANEOUS SERVICES <br /> I. .3R NVIRONMEN'�A� <br /> PE ,II�'�skVICESS�P� <br /> (Application DateIO.�71 (�$ Business/Name To Appear On Permitcel <br /> � — <br /> F Type Permit/Service Requested: ort 1, <br /> I,( ti zgn,lc_S- -Lt./'/"IT/�"' Address �J 33Lp Sf'tCc t,J <br /> i Applicant Name��-- <br /> 8 SCcGrC. O. L&A-AIL� lli 9SVa7 Business Telephone No. Emergency Telephone No. <br /> a Property Location/Address h <br /> Sfvc <br /> `Property Owner Address <br /> loperator'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 ❑ LIOUOR 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 ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ HOTEL/MOTEL/No.of Units <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3, WATER QUALITY 13 WATER SAMPLE (Bacterial) 13 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 /> :ENNEL/Runways /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method - <br /> Solid Waste Disposal Method <br /> er Sypply Source Animal Waste Disposal Method <br /> Wat <br /> 6. CONSULTATION FEE <br /> ❑ .PLAN CHECKING FEE <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection C3 Semple❑ Title Company <br /> Sewage System Inspection <br /> ❑ 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 th' applicatio nd that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, d ules d a so e San Joaquin Local Health District. <br /> Title Date <br /> APPLICANT'S SIGNATURE _ <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 A Receiv REMITBy uly 31 <br /> BASE ' EXPLANATION BILLING REMITTANCE E AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUN <br /> 2/hrs @ Ta P� <br /> FEE $70.00 $35/ 4 10S i 6 5•cSZ� <br /> LESS <br /> PRORATION <br /> PLUS DAYS FRO BILLING D E. <br /> PENALTY <br /> (.,OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit ,u, issuance Date Mailed Delivered <br /> H PERMIT/SERVICES 1501 E.HAiELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALT <br />