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Applications Will Be Pr ad When Submitted Properly Completed. Be Sure To Sign The Applicatioz. y <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANTS AND/OR FOOD ESTABLISHMENTS,ROUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER S MPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIOI S Lic. NO. <br /> irENSE AND/OR POULTRY RANCHES AND IENNELS Re ISL NO. <br /> ;TRATION - MISCELLANEOUS SERVIC S g <br /> 1, BER <br /> Color <br /> rApplication Dare Business/Name To Appear On Permits <br /> 9a Type Permit/Service Requested: <br /> a Applicant _�_Alal Add resjgI- —fin <br /> nBusiness Te ephone No. 5�'ago/ Emergency Telephone No. <br /> a Property Location/Address <br /> aProperty Owner /. Addres /�2J6 �n� 1Ag sOk";10 <br /> Operator's Name !T _ Addres <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 .0-FOOD SALVAGER ❑ FOOD DE ONSTRATION�� ❑ 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 PAYMENT <br /> 2. HOUSING <br /> ECE <br /> ❑ HOTEL/MOTEL/No. of Units CERTIFICATE OF OCC PAN / <br /> ED <br /> ❑ MOBILE HOME PARK/No. of Spaces M�A 1 <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL 'rlr�� <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) 'NVIRONM��ENTAt_ HgALTH <br /> 4. RECREATIONAL HEALTH 1:1 SWIMMING POOL El SPA C1 WADING POOL ❑ NATUR99W4/IM1&,0LCA8E <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 Sly Source Animal aste Dis osal Method <br /> 6. W CONSULTATEE ION Fvl / "%W- ,5 J,,6 moo. 3x45 3—a <br /> 7. ❑ .PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection El 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 the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, andrules and regulations of the San Joaquin L cal e <br /> Health District. f �y <br /> APPLICANT'S SIGNATURE X Title A,,;,� /air» <br /> � Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> AMOUNT DUE CHECKED <br /> DATE DA E REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION 1 <br /> PLUS j <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />