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Applications Will Be Pr sed When Submitted Properly Completed. Be SAIIII11111wo Sign The Application. <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />ENGINEER'S AND/OR IF VEHICLE NV VE; UG <br />APPLICANT'S AND/OR FOOD ESTABLISHMENTS, HOUSING Make <br />CONTRACTOR AND/OR PUBLIC POOLS, WATER SAMPLING <br />BROKER AND/OR REAL ESTATE INSPECTIONS Lia. No. <br />.irENSE AND/OR POULTRY RANCHES AND KENNELS <br />3TRATION MISCELLANEOUS SERVICES Regist. No. <br />I, .8ER _,. Color <br />f Application Date Business/Name To Appear On Permit <br />u)Type Permit/Service Requeste <br />a Applicant Name �+� address <br />ausin s Telephone No. Emergency Telephone No. <br />a Property I nratinn/AririrPca - <br />eNkina <br />Property Owner 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 MARKET <br />❑ FOOD-PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br />❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR 3 ITINERANT RESTAURANT <br />11 CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br />11 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 11 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 <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 <br />T. 0 PLAN CHECKING FEE <br />B. 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, 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 />BASE <br />EXPLANATION <br />BILLING <br />REMITTANCE <br />$ AMOUNTDUE CHECKED <br />DATE <br />DATE <br />REMITTED AMOUNT <br />FEE <br />LESSt <br />:PRORATION. <br />..,fie <br />L�Yi <br />e Y i <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />Received by Date Receip4 No. Permit No. Issuance Date Mailed Delivered <br />APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT /SERVICES 1601 E. HAZELTON AVE., P.O. Box 2009 STOCKTON, CA 95201 <br />