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Applications Will Be Prr sed When Submitted Properly Completed. Be Sv, To Sign The Application. <br /> "11✓ APPLICATION ,,rs' <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEERS AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S-AND+OR F000 ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING <br /> BROKEN AND/OR REAL ESTATE INSPECTIONS Lic No --- ---- --- <br /> ir'ENSE AND/OR POULTRY RANCHES AND KENNELS Regist- No. <br /> 3TRATION MISCELLANEOUS SERVICES ------- -- <br /> k. .dER -- -.. ,�1 C Color - <br /> Application Date_ _- „' ` d Business/Name To Appear On Permit <br /> _ - - - - — <br /> v,Type Permit/Service Requested: , ,a�t. C hPC/L - - -- <br /> aApplicant Name � F % N / � Address ^ 35 J2 '� <br /> O ' ' �� T��OS Business Telephone N4. c y Emergency Telephone No. <br /> aProperty Location/Address <br /> iProperty Owner- �-C �'� /�L -- Address <br /> (.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 ❑ 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 ❑ 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 ❑ SPAY ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> r :ENNEL/Runways __—__ -T /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. ❑ ULTATION FEE -- <br /> 7. PLAN CHECKING FEE c" ��� <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 SITE ❑ 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 <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.HAZELTON AVE.,P.O.Box 2004 STOCKTON.CA 95201 <br />