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Applications Will Be Procdftd <br /> When Submitted Properly Completed.Be Sur Sign The Application. <br /> wr <br /> aaza .. <br /> APPLICATION <br /> VIRON ENTAL HEALTH PERMIT/SERVICES <br /> NP4NEER's AND/OR IF VEHICLE INVOLVED,GIVE <br /> ' APPLICANT'S AND/ORFOOD ESTABLISHMENTS,HOUSING <br /> CONTRACTOR AND/OR ` `;q UMake <br /> PUBLIC POOLS.WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> .trENSE AND/OR _ POULTRY RANCHES AND KENNELS Regist. <br /> iTRATION 1 TIL F MISCELLANEOUS SERVICES -- ---- <br /> I. .8ER COIOP -- -- <br /> r – <br /> [Application Date _ <br /> __---- Business/Name To Appear On Permit <br /> (*Type Perm it/Se rvi___Re ested: <br /> a Applicant Name ai4& Address_ <br /> J. Business T lephone Na: _ _ Emergency Telephone No, <br /> o. <br /> a Property Location/Address__ <br /> aProperty Owner__ ® Address P _ ® i <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 <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 _ <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY 0 WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) _ __ <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL 13 SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. 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 Ptply Source _._ Animal Waste Disposal Method <br /> 6. Ir.' ONSULTATION FEE <br /> 7. VPLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample Title Company _ <br /> Sewage System Inspection ❑ Address — Tele. No. <br /> Escrow No. - <br /> Seller Seiler Address -_ <br /> Telephone No. _— Seller Agent Name <br /> Service Request For Date ---- -- <br /> 1 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. <br /> APPLICANT'S SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1$Received By July 31 <br /> RE <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE C CKED <br /> DATE BATE REMITTED MOUNT_ <br /> FEE ® , , 8/21/90 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date lWpt No. Permit No. Issul-ilwate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTUN AVE.,P.O.Dox 2009 STOCKTON,CA 95201 ----- <br />