Laserfiche WebLink
Appl ca l I e ro ss W ubmitted Properly Cornpleted. Be Sure To Sign The Application. <br /> APPLICATION <br /> ENGINEER'S AND/OR <br /> ENVIRO NTAL HEALTH PERMIT/SERVICES GENERAL <br /> �3 '�g?9 <br /> r AUG <br /> I APPLICANT'S AND/0R FOOD ESTABLISHMENTS,HOUSING �,r VEHICLE 1 V LVED, GIVE <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING �- Make <br /> BROKER AND/OR <br /> L ( r CAL REAL ESTATE INSPECTIONS LIC. <br /> t CENSE AND/OR LO � � I <br /> I REGISTRATION SAN JOA POULTRY RANCHES AND KENNELS E��J <br /> NUMBER HEALTH D4STRICT MISCELLANEOUS SERVICES `Rst. O.t# <br /> U r <br /> [Application Date 8/21/79 Business/Name To Appear On Permit V <br /> coType Permit/Service Requested: <br /> z D.A. arrish & ons °Q° ox 1450 Stockton <br /> Applicant Name Address P <br /> i 0. Business Telephone No. Emergency Telephone No. <br /> a Property Location/Address 5058 Hickory Lane, Stockton <br /> a Property Owner Max Peterson <br /> Address <br /> L Operator's Name Address <br /> 1. .FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> r ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> I ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION C1 FOOD VENDOR <br /> VENDING MACHINES/No, of OBI =- <br /> ❑ MLE 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 D 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 4r <br /> 6. 'CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT i <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <br /> Escrow No. <br /> Seller Seller Address — ;r <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 Y 7� <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UW ❑ PER SITE ❑ EACH ❑ January 1 &Received By Janua <br /> ry 3111 July 1 &Received By July 31 , <br /> BASE BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT n <br /> FEE $30.00 Reinspection 8/21/7 ►yxb $30.00 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuance Date Mailed a� Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />