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nI.-L L-ili .IAN U b Iy <br /> Applications WIII Be`Sal When Submitted Properly Completed. Be To Sign The Application. <br /> APPLICATION <br /> ♦ pAfL IFONMENTAL HEALTH PERMIT/SERVICES 3 a <br /> ENGRGEER'S AND/OR '��� LVED,GIVE <br /> APPLICANT'S AND/OR pEGEIVED FOOD ESTABLISHMENTS,HOUSING <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING = " <br /> BROKER AND/OR p �n �990 REAL ESTATE INSPECTIONS Lie. NO. <br /> (CENSE AND/OR e'e' 1� POULTRY RANCHES AND KENNELS SANR�gIs[. ttlp. <br /> 3TRATION kN JOAQUIN COUNTY MISCELLANEOUS SERVICES <br /> I. .BERPUS tOolor . <br /> -_— PUBLIC HEALTH SERVICES <br /> q"ENTALHEALTHDIVISION �r� �, ENV�lONMI rIAeHL.1_, <br /> f Application Date ,?II J'.- Business/Name To Appear On Permit Ace C ENVJAt�wm <br /> eType Permit/Servic�e�FjlO=�quested: Oh nf2l=b C_Y� <br /> z.Applif,a�nt Naa — Address 1 gp b4NE � �yGf'`�-{�M <br /> M Ci/`f . ��i�n 9/ Busi ss Telephone No. Emergency Telephone No. <br /> 6 <br /> i Property Location/Address <br /> i Property Owner Address <br /> -tOperator's Name &eCA Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Seating Capacity <br /> cti <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 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 /> :ENNEL/Runways /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste D osal Method <br /> Water S�u y Source Animal Waste Disposal Method <br /> 8. C4Y ONSULTATION FEE <br /> T. ❑ .PUN 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 h ve prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, n rules and ulations of the San Joaquin Local Health District. jj <br /> APPLICANT'S SIGNATURE 411 Title bete <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY C1 PER UNIT ❑ PER SITE 11 EACH C3Janu y 1 A eceived By January 31 July 1 A Received By July 31 <br /> BILLING ?UE <br /> REMIT <br /> BASE EXPLANATION DATEREMITTED AM NT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS �.�- Cpni OA-) 1/4/90 <br /> PRORATION <br /> PLUS X/,S _ <br /> PENALTY / <br /> OTHER LI\�A._TICJ V4,�1_L BE/'\pi'_IL✓ �' OUNTS 3c. <br /> —FROM BILUMG IE. <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 2009 STOCKTON,CA 95201--— <br />