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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> IRO I ECNTtAL.HEALIIr66�21Y <br /> gI1. / E�S GENERAL <br /> ENGINEER'S AND/OR UESTIONS CALL xt, IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR �rFOODESTABLISHMENTSNG Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. NO. <br /> LICENSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> REGISTRATION MISCELLANEOUS SERVICES <br /> NUMBER FEE IS DUE WITH APPLICATION BEFORE DUE DATE AS SHO'R"r.E'OW <br /> [Application Date Business/Name To Appear On Permit <br /> FType Permit/Service Requested: <br /> a Applicant Name Richard ''e!. Konig, Attorney Address 305 N. E1 Dorado, Suite 305, Stockton <br /> dBusiness Telephone No. Emergency Telephone No. <br /> a Property Location/Address <br /> aProperty Owner Address <br /> L 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 ❑ 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 /> ❑ KENNEL/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 ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <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 ttle work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r regulations <br /> of the S n J uin Local Health ri <br /> APPLICANT'S SIGNATURE X Title Date <br /> FOR DEPART T 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 26.75 107 copies at $.25/e ch $26.75 X <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY P <br /> OTHER 30 DAYS-50",; of BASE FEE T SHOWN BEL W <br /> OTHER DAYS-2511 of BASE FEE <br /> 5 22 �G �-- <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.Box 2009 STOCKTON,CA 95201 <br />