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s <br /> Applications Will Be Prod When Submitted Properly Completed. Be Su Sign The Application. <br /> t APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> IF VEHICLE INVOLVED, GIVE <br /> ENGINEER'S AND OR FOOD ESTABLISHMEHTS,HOUSING Make - <br /> APPLICANT'S AND,'CR PUBLIC POOLS.WATER SAMPLING <br /> CONTRACTOR ANDiDR REAL ESTATE INSPECTIONS Lic No. <br /> BROKER AND/OR POULTRY RANCHES AND KENNELS Regist. No - <br /> IrENSE AND/OR MISCELLANEOUS SERVICES <br /> 3TRATION Color — --- - - - - <br /> .BER <br /> Application Date�1�_'' - - Business/Name To Appear On Permit = --- -- - <br /> ,nType Permit/Service Requested: <br /> � r � Address - <br /> Applicant Name-^,-' — - - -- - <br /> `i /✓ Business Telephone Na - — Emergency Telephone No. - <br /> a - — <br /> a Property Location/Ad ress <br /> Property Owner_ � Address <br /> operator's Name g q g <br /> 1. FOOD ESTABLISHMENTS - <br /> Total Building S Footage Restaurant, Maximum Seating Capacity <br /> ❑ MEAT MARKET <br /> C3 RESTAURANT 1:1 FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE BAKERY <br /> El FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE <br /> ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> El VENDING MACHINES/No. of _- ❑ MOBILE FOOD PREP. UN47 13 VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees - - -- - REGF1V E0 <br /> ALL APPLICANTS: Total Employees Including Operators - - - <br /> 2. HOUSING ❑ CERTIFICATE OF OCCUPANCY OCT <br /> HOTEL/MOTEL/No. of Units .. - <br /> ❑ MOBILE HOME PARK/No of Spaces ENVIRONMENTAL. HEALTH <br /> 3. WATER QUALITY 13 WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY © WATER HAULER pE1IT�S�RVICES <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 /> - <br /> Animal Waste Disposal Method <br /> Water Supply Source <br /> 6, CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING. FEE - <br /> B. REAL ESTATE <br /> REQUEST: Water Well inspection SampleD Title Company - - - -- - - <br /> Sewage System Inspection ❑ Address - -- <br /> -Tele. No.- <br /> Escrow No. - -- - <br /> Seller - Seller Address --- <br /> Telephone No _ Seller Agent Name - - - <br /> Service Request For Date - - - - - -- - - <br /> I hereby certlfy 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 - - - <br /> 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 ByI July 31 <br /> REM <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT_ <br /> LESS <br /> PRORATION - <br /> PLUS — <br /> PENALTY <br /> OTHER 6 -� <br /> OTHER <br /> Date <br /> Received by <br /> 1601 E.HAZELTON AVE., Boy <br /> Date sept No Permit No. Is P.O..Box <br /> Delivered 2009 STOCKTON,CA 9520 <br /> APPLICANT—RETURN ALL COPIES TO- ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />