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)001 <br /> 4PNVIMUNMENTAL HEALTH PERMIT/SE E <br /> ENGINEER'S AND/OR S <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING IF VEHICLE INVOLVED,GIVE <br /> 41-"GINTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. NO. <br /> 1rENSE AND/OR POULTRY RANCHES AND KENNELS <br /> ;TRATION MISCELLANEOUS SERVICES Regist. No. <br /> I. BER ---— —_. <br /> Color <br /> n <br /> Application DatE I Business/Name To Appear On Permit . CO <br /> Type Permit/Service A uested: r/ ` </? <br /> `Applicant Name <br /> u _____ _ Address GDL-P✓ <br /> IL Business Telephone N 4 -�S 3 Emergency Telephone No. <br /> `Property Location/Address ,/�f_n( <br /> C Property Owner C D_s _ Address �`�� S <br /> -LOperator's Name JiAK-Y Address C 6L 5 <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 /> as 2. HOUSING <br /> ❑ HOTEUMOTEUNo.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 ❑ 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 :ENNEURunways /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 /> 7. K PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection Sample❑ Title Company <br /> i 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 tha +I have pr ared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state la s, an rui alatiorts of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X L fCofe�". Oate <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 A Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> _ DATE_ DATE REMITTED AMOUNT <br /> FEE — — -- -- <br /> LESS V E 1171 — <br /> PRORATION <br /> PLUS <br /> PENALTY J <br /> OTHER --INVIUNMENTAL HEA <br /> !r - <br /> t=C <br /> OTHER P IT'SERVICES <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.Boa 2009 STOCKTON.CA 95201 <br /> t . <br /> - <br /> i <br />