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Applications Will Be Pred When Submitted Properly Completed. Be S o Sign The Application. <br /> 0 APPLICAT10N <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S ANDiOR 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 Lia No. --- <br /> irFNSE AND/OR POULTRY RANCHES AND KENNELS Regist No <br /> 3TRATION MISCELLANEOUS SERVICES <br /> Calor - <br /> I. ,BER ---- - --- - <br /> Application Date _ - --- - Business/Name To Ap earO Per it <br /> � J <br /> oType Permit/Service Requested:- <br /> E <br /> aApplicantN e �-- In - - Address _ <br /> _� _. B ine Tel hone NO. Emergen eie No. <br /> CL P <br /> IL Property Location/Addr <br /> LF.Location/Addy <br /> �Property Owner i _ _ Address <br /> LOperator'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 __e ❑ 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 ❑ 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 /> Water Supply Source _ imal Was Dispo$al Method <br /> 6, CONSULTATION FEE VIAA&I `r - <br /> 7. ❑ PLAN CHECKING FEE PAYMENk <br /> 8. REAL ESTATE IRF-CF-1 D <br /> REQUEST: Water Well Inspection 13 Sample Title Company - <br /> Sewage System Inspection Cl Address _ Tele. No. ��yyL+ {1 <br /> Escrow No. - - - do `� <br /> Seiler _ -_ __ - - Seller Address <br /> Telephone No. Seller Agent Name _ nitrznNM�NTAL HEALTH <br /> ES <br /> Service Request For Date -- __ . . __—__— _ 11pipR.".TrSFR� �� <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 S 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 ' oz <br /> - <br /> PLUS <br /> PENALTY <br /> OTHER DAY <br /> ^,T ' <br /> OTHER <br /> i <br /> Rece d by Dale Receipt No Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON,CA 95201 <br />