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t Applications Will Be RIIIIIIIIIIessed When Submitted Properly Completed. BeTo Sign The Application. <br /> I <br /> If APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING - --- - <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. NO. <br /> ,IrENSE AND/OR POULTRY RANCHES AND KENNELS Ra ISL NO. <br /> 3TRATION MISCELLANEOUS SERVICES g - - <br /> I. .SER c• Color <br /> (Application Date Business/Name To Appear On Permit I(^L= IliCO - <br /> oType Permit/Servic Requested: L26 P144%, vie 1 a U <br /> i <br /> AP licant ame �� C Addr ss T� J�-S (��� Cl <br /> uBusiness Telephone No�.1GY �i:1 y" /q G 53 Em rgency Telephone No. <br /> L <br /> Location/Address Iii e- <br /> aProperty Owner Address /e <br /> Is <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 ❑D?i�W <br /> ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ E <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees t4l <br /> ALL APPLICANTS: Total Employees Including Operators L' <br /> 2. HOUSING E�V B� <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCC2 � 3;j <br /> ❑ MOBILE HOME PARK/No, of Spaces <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑NOPOF PUBLIC SERVEDUBLIC WATER (Connections) <br /> SURFACE WATER SUPPLY ❑ WATER HAULER <br /> MjIS NV\CESS <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BA5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> r :ENNEL/Runways /Animal Population No. No. of Confining Cage <br /> Sewage Disposal Method - <br /> Solid Waste Disposal Method <br /> Water S ply Source Animal Waste DisposalMethod <br /> 6. CONSULTATION FEE re- etc G4 V 4 ii Qln.r elm o r X l e. ( e v 1 e I <br /> T. ❑ .PLAN CHECKING FEE <br /> 6. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample 13 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 e epared this ap lication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws a d les a d egulat' ns of a San Joaquin Local Health Distri ,QQ <br /> APPLICANT'S SIGNATURE X Title ` � i Dale k —�—f/ / <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 d Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> / DATE DATE C REMITTED AMOUNT_ <br /> FEE $� L • 75 <br /> LESS ca <br /> PRORATION <br /> PLUS <br /> PENAUNES WILL BE APP !EDTE) ",�, <br /> PENALTY FR M BILLING OVE. <br /> OTHER -- -----_.--- <br /> OTHER 1/23�89 h / a ✓ <br /> Received by Date— Itipt No. Permit No. IsDale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boy 2009 STOCKTON,CA 95201 <br />