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0 6 now <br /> I <br /> I APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVt <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING Make _ <br /> CONTRA CTOR.AND/OR PUBLIC POOLS,WATER SAMPLING - - "---'— -- <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> ir'ENSE AND/OR POULTRY RANCHES AND KENNELS RBgISt. NO. <br /> 3TRATION MISCELLANEOUS SERVICES <br /> i. dER - - Color <br /> f <br /> f Application Date.. 712 Z __ Business/Name To Appear On Permit 6TS <br /> ._ ��t +�trr1]•c / ___. __— <br /> ,nType Permit/Service Requested:-- _P — <br /> r! W� D Bax 2LyZ MQrc���-L 9,13 TO <br /> {Applicant Name *` Addr ss ��) !1t3��-5�VS <br /> — Business[Telephone No. b - — Emergency Telephone No. <br /> -Property Location/Address_.1-�_.vuv i� R M �� <br /> a <br /> Property Owner urr q Address � (0QS3p <br /> Operator's Name 5A l'-1e Address <br /> t. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT Cl COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIOUOR 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 QUALITY ❑ WATER SAMPLE (Bacterial) Cl 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 __ T Animal Waste Disposal Method <br /> 6. CONSULTATION FEE <br /> 7. ❑ PLAN 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 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 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE f <br /> BASE EXPLANATION AMOUNT bUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS - <br /> PRORATION <br /> PLUS - <br /> PENALTY <br /> OTHER <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.Ban 2009 STOCKTON.CA 95201 <br />