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` IF Vtl'iII LG INVVL-V .-, *4 <br /> ENGINEER'S AND,'OR FOOD ESTABLISHMENTS,HOUSING Make - -- -- <br /> APPLICANT'S AND/OR PUBLIC POOLS.WATER SAMPLING _ - <br /> CONTRACTOR AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> BROKER AND/OR <br /> i�ENSE ANDloR POULTRY RANCHES AND KENNELS Regi5t. No. <br /> MISCELLANEOUS SERVICES Color .- - - <br /> 7iTRATION + w — <br /> I, BER <br /> iApplication Date- ._ ___ ___ Business/Name To Appear On Permit - <br /> �Type Permit/Service Requested: <br /> Address -z. Applicant Name - -- - -- - N - <br /> Business Telephone No. - --- -- -- Emergency Telephone o. <br /> - - <br /> a Property Location/Address -- - -�-- - - - - - - - - - <br /> Property Owner _ _ Address <br /> Operator's Name __ -- - - - - - _ Address - - - - <br /> 1. FOOD ESTABLISHMENTS Total building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT 11 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 -- -ALL APPLICANTS: Total Employees Including Operators -- <br /> 2. HOUSING <br /> 1:1HOTEL/MOTEL/No. of Units - ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER OUALITY C1 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 /> So4id Waste Disposal Method -- <br /> Water Supply Source _ Animal Waste Disposal Method — <br /> 6. ❑ CONSULTATION FEE <br /> i !Yr�: T11Stc: ) I._1L1Otl <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection 11 Sample❑ 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 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 ❑ ly 1 &Re vedE9MyITJuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOU T DUE CH KED <br /> DATE DATE REMITTED AM LINT_ <br /> FEE <br /> LESS — <br /> PRORATION <br /> PLUS <br /> PENALTY _ -- - <br /> OTHER <br /> OTHER <br /> Received by Date <br /> 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 5TOCKTON,CA 95201 <br />