Laserfiche WebLink
Applications Will Beftd When Submitted Properly Completed. Be 1 Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING <br /> rxlrsA -Make <br /> CONTRACTOR AND/OR ` 1 c PUBLIC POOLS.WATER SAMPLING "g A� - <br /> REAL ESTATE <br /> ONS <br /> BROKER AND/ORNSE AND/OR �' J'; POULTRY RANCHES ANID KENNELSCEIVlc.egist No._ <br /> 3TRATION ►-L ^ n Q \ MISCELLANEOUS SERVICES (� (� (� �t y� ---- - <br /> BER 1�� ILL` l 00 CT 0 J t0 f'EJOIor - - <br /> nnmill t::0� ;Y <br /> Application Date -�Q `_1 _- Business/Name To A SAN JOAN I i <br /> i PP Appear On Permit PUBLIC HE a-T-W cf:oi,r <br /> inType Permit/Service Requested' __.--__ ______-___ ._ _ . ._. __ __ I -f" 1)iV1 'ION <br /> Z App iicant Name - �_ �f- -- ____________._ Address ` <br /> a _- Ct__ anG.�. Business Telepho a NO. Emergency Telephone No. <br /> a Property Location/Address- +C�� G - Fr&�mr. _ -r _ ..I _ aA-___v-V-A'Qn-% `` <br /> aProperty Owner - _- _ Address <br /> [Operator's Name ____ ___._______ -- __._ -_____ _ Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARK T 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 Operator,$ <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 El POOL 11 SPA WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Bir <br /> r :ENNEL/Runways __ /Animal Population No. _- No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source Anima Waste Disposal Method <br /> 6. CONSULTATION FEE f15 —i �1 ��- Q-1 <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 work will be doneI accordance with San Joaquin County <br /> ordinances, state laws. <br /> APPLICANT'S SIGNATURE X -_ __.-__ Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Janu 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE C ECKED <br /> AMOUNT <br /> 9121190 <br /> j FEE <br /> LESS <br /> PRORATION <br /> PLUS t <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date h—eipt No Permit No Issui r—Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.aox 2009 STOCKTON,CA 95201 --- <br />