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Applications Will Be Prc ,sed When Submitted Properly Completed. Be Sur-To Sign The Application. <br /> 4. APPLICATION „w, <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S ANDrOR IF VEHICLE INVOLVED, GIVE <br /> APPLBCANT'S AND/OR FOOBL IC POOLS,WATER SAMPLING ESTABLISHMENTS, HOUSING Make <br /> CONTRACTOR ANDiOR PUBLIC <br /> BROKER AMD/OR REAL ESTATE INSPECTIONS LIC. No. -- — <br /> irFNSE AND/OR POULTRY RANCHES AND KENNELS Regist. No —_ <br /> 3TRATION MISCELLANEOUS SERVICES <br /> C <br /> BER alor <br /> - — <br /> Application Date 140 siness/Name To Appear On Permit - <br /> ,nType Permit/Service Requested:.. • Z'`;7-,L"'_r"7eC - ---- - --- - 67 - <br /> ` �1�e _ Address- ��� y( � <br /> i Applicant Name <br /> U _ j� i� _ � Business Telephone Np. Emergency Telephone No. <br /> FL <br /> 4Prope0y Location/Agdress,. .f <br /> {Property Owner— rl�I�l�l1L -- Address _'7 <br /> L Operator's Name — 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 MACHINES/No. of - ❑ MOBILE FOOD PREP. UNIT El 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 /> ❑ MOBIL€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 /> 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 _ Animal Waste Disposal Method <br /> 6, O 0WJULTATION FEE <br /> 7. PLAN CHECKING FEE t�'2 _4� <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 — Date . <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER$ITT_ ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> - -------- - REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> �`'`/ DATE DATE REMITTED AMOUNT <br /> FEE ! ,1.� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER 1/�© 06V" -- -- <br /> OTHER T I / t5FAii­7C_ S_Wr y oG AIRVd - <br /> 17 D <br /> flecewed 4y 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 2009 STOCKTON.CA 95201 - <br />