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Applications Will Be PrOed When Submitted Properly Completed. Be S* Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEERS AND OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND:OR FOOD ESTABLISHMENTS.HOUSING Make <br /> CONTHACTOR AND OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND,OR REAL ESTATE INSPECTIONS LIC. No. <br /> ('ENSE AND OR POULTRY RANCHES AND KENNELS Reglst No <br /> TRATION MISCELLANEOUS SERVICES <br /> i. .oER Color <br /> k Application Date -V Z) Business/Name To Appear On Permit <br /> Ff Type Pelrnit/Service Requested: <br /> {y� <br /> a Ap Ilcant Name 4� St-PQ k u Address� <br /> �- - -- - - - - <br /> POE) S�`3 � B slness Telephone No. Emergency p <br /> ML 2�4 � - Emer enc Telephone No. _ <br /> r Location/Add e _` ._� P-V6. <br /> - ---- <br /> Property Owner Address <br /> Operator's Name 51 - __ . 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 MACH,iNES/No. of MOBILE FOOD PREP UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees _. _ . <br /> ALL APPLICANTS: Total Employees Including Operators <br /> ... <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units _.__._ .____._ ❑ CERTIFICATE OF OCCUPANCY V <br /> ❑ MOBILE HOME PARK/No. of Spaces - <br /> 3. WATER OUALITY ❑ 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 /> r 'ENNEL/Runways /Animal Population No. -__ No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method ___ _. �• <br /> Water Supply Source _ _-� _ __- Anifflal Waste Disposal Method <br /> 6. CONSULTATION FEE -Vj�'- C71��'_IL_L- <br /> 7. 4 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 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 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNIJALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I &HeLerved By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> E'A:;L EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> _ - AMOUNT <br /> FEE t.Obfta- tD '[j11D(_-IESS <br /> _._ -. --- - ...- ----- 1a- •S - <br /> PRORATION , �I",!� .ISI r;�� ,^,�",� - - .,;S E AC3U., v <br /> P1.us DOS o�aN3 a�u,vcA — <br /> PENALTY <br /> OTHER 52. saf�2. l--a � .--- - - L <br /> OTHER 11/I-5/18 <br /> a - - ---s tips - -------- <br /> Rvice+wd by Data Rec:ecla No Pernul No Issuance Dale - Mailud Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITr'SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />