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L, Applicgtions Will Be Pr ed When Submitted Properly Completed. Be <br /> APPLICATION So Sign The Application. <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> IF VEHICLE INVOLVED, GIVE <br /> ENGINEERS AND.-OR FOOD ESTABLISHMENTS,HOUSING Make <br /> APPLICANT'S ANOIOR PUBLIC POOLS,WATER SAMPLING - - - - <br /> CONTRACTOR ANO/OR REAL ESTATE INSPECTIONS Lic No, -. --OER AND/OR POULTRY RANCHES AND KENNELS <br /> SE AND/OR Regist. No. <br /> 3TRATION MISCELLANEOUS SERVICES Color <br /> I, dER _ 2 <br /> Application Date <br /> BusinesS/Name 7 Appear On Permit" --- - -- <br /> Type Permit/Service equested: -- &2P�i'OJ y <br /> a Applicant Name y ------ Address_- -3 --�I <br /> g / <br /> Business Tele hone No.� =.3� � - Emergency Telephone No. <br /> arop "Property Location/Address _.. --A� '-M n <br /> �� Address ` L 7©O <br /> Property Owner <br /> 4 Address - <br /> Operator's Name -- - - <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 MACHINES/No. of -_. ❑ MOBILE 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 11 WATER SAMPLE (Bacterial) El 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 /> 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 Ani al Waste Disp Sal Method _ <br /> 6. K CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE <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 - <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 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receiroad By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILI REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE C7 <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.HAZELTDN AVE.,P.O.li 2009 STOCKTON,CA 95201 - <br />