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Applications Will Be PNEIRONMENTAL <br /> sed When Submitted Properly Completed. Be S To Sign The Application. <br /> APPLICATION <br /> t HEALTH PERMIT/SERVI S <br /> FNGINEER'S AND/ORAPPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING p Q►�M EKT IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING R E CEI V ED Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> r-ENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES �- '. 198Regist. No. <br /> i, .6ER Color <br /> ,�_ ENVY OW NTAL HEALT�i <br /> Application Date Business/Name To Appear On Permit <br /> ,*Type Permit/Services Requested: r <br /> a A licant Name ' ' ��N Address— <br /> Business <br /> ddress Business Telephone No. Emergency Telephone No. <br /> aProperty Location/Address w <br /> aProperty Owner — L 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 M K <br /> ERET <br /> ❑ FOOD PROCESSING PLANT 13 COMMISSARY E] ICE PLANT ❑ BAKY <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. HOUSINGHODERY LEE & ASSLICIAT "S <br /> IJHOTEL/MOTEL/No. of Units 1:1CERTIFIC TIMARR IVOCY f l <br /> ❑ MOBILE HOME PARK/No. of Spaces ! JOB NUMBER <br /> 3. WATER QUALITY 11WATER SAMPLE (Bacterial) ❑ CHEMICAL PAYMENT APPROVED BY <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) .1 PAYMENT PROCESSED BY <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA 11 WADING POOL 11NAZiIi$Q'ICN(MRG 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 /> Water Supply Source _ Animal Waste Disposal Method <br /> 6. ODCONSULTATION FEE — <br /> 7. 0 PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection Sample❑ Title Company <br /> Sewage System Inspection ❑ 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 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 /> 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 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT_ <br /> FEE 1-25—:81 .M <br /> LESS <br /> PRORATION PFM,41 fi r' I n , <br /> T r \JI jUE-ACCOul'ITS 3C <br /> PLUSDAYS Hd JVi �1LLl vG DIANE <br /> PENALTY <br /> OTHER �j z r� LQ <br /> OK 2/6/89 <br /> OTHER *,52,57D <br /> 7?7L7,If7 <br /> Received 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.Bo=2009 STOCKTON,CA 95201 I <br />