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w ' APPLICATIO <br /> I ' RONMENTAL HEALTH PE <br /> ERMIT/SERVI&L3 <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED,GIVE <br /> APPLICANTS AND/OR FOOD ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR = gg REAL ESTATE INSPECTIONS LIC. NO. <br /> ir.FNSE AND/OR r POULTRY RANCHES AND KENNELS R i5t. No. <br /> 3TRATION MISCELLANEOUS SERtftCt S <br /> I. ,, 8ER __ Color <br /> •f Application Date Business/Name To Appear On Permit <br /> oII Type Permit/Service Requested: <br /> Ap IiCant Name Add- ssu(aS <br /> UG L} `}- <br /> � Business T e hone N 32 Emergency Telephone No. <br /> t Property Location/Address <br /> i Property Owner Address <br /> LOperator's Name Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKE=T 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 FODD 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 /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> .ENNEL/Runways /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source nimal Waste Disposal Method <br /> 6. CONSULTATION FEE U69 94 fes; C, <br /> 7. PLAN CHECKING.FEE <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 the worli 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 /> ♦ I; <br /> APPLICANT'S SIGNATURE X Title l P Date <br /> w <br /> FOR DEPARTMENT USE ONLY 4 <br /> Fee Is Due: © ANNUALLY ER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July t &Received By Ju$y 31 <br /> A <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION PATE DATE REMITTED AMOEJNT DUE CHECKED <br /> �`�— AMOUNT <br /> (� <br /> FEE . 0, !,1h 'c'o <br /> LESS <br /> PRORATION <br /> PLUS <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 PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2M STOCKTON,CA 95201 <br />