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ENGINEER'S AND'OR APPLICANT'S AND/OR :ONTRACTOR AND/OR BROKER ANO/OR ir'ENSE AND/OR 3TRATION dER Applications Will Be Prc ved When SubnmitttPLproperly iCATION Completed. Be SLw0 Sign The Application. `� ENVIRONMENTAL HEALTH PERMIT/SERVICES FOOD ESTABLISHMENTS, HOUSING PUBLIC POOLS. WATER SAMPLING REAL ESTATE INSPECTIONS POULTRY RANCHES AND KENNELS MISCELLANEOUS SERVICES IF VEHICLE INVOLVED, GIVE Make Lic. No. Regist. No. Color Application Date _____ —_— Business/Name To Appear On Permit ,Type Permit/Service Requested:_ -- r+ Applicant Name _ Address Business Telephone No. Emergency Telephone No. Property Location/Address -= ---- ------ - Property Owner _ _ .`. ---- Address -_ — - i Operator's Name .._ -- Address -- 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR ❑ VENDING MACHINES/No. of — ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE ❑ FOOD CROP HARVESTING/No. of Field Employees ALL APPLICANTS: Total Employees Including Operators 2. HOUSING ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY ❑ MOBILE HOME PARK/No. of Spaces 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) 13 CHEMICAL ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER NO. OF PUBLIC SERVED (Connections) 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds .ENNEL/Runways _ /Animal Population No. No. of Confining Cages Sewage Disposal Method Antic! Waste Disnnsal Method •- Water Supply Source _ Animal Waste Disposal Method 6. ❑ CONSULTATION FEE T. ❑ PLAN CHECKING FEE S. REAL ESTATE REQUEST: Water Well Inspection 13 Sample❑ Title Company Sewage System Inspection ❑ Address Tele. No. Escrow No. - Seller Seller Address Telephone No. — Seiler Agent Name _ Service Request For Date I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. APPLICANT'S SIGNATURE X Title Date f FOR DEPARTMENT USE ONLY Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 6 Received By January 31 ❑ July 1 6 Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE i.J .�" / - `_�) �;✓ r � `J �� _ i � _ LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered -- APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE.. P.O. Sox 2009 STOCKTON, CA 95201