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• Applications Will Be Prosed When Submitted Properly Completed. Be Sur To Sign The Application. <br /> F APPLICATION *PAYMENT' <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICER E C E I V E D <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S ANb/OR // FOOD ESTABLISHMENTS,HOUSING JAN <br /> hI ry�pp0��d 11 <br /> CONTRACTOR AND/OR ':� PUBLIC POOLS.WATER SAMPLING JAN 1 I IJ�i:'1 _ <br /> BROKER AND/ORF REAL ESTATE INSPECTIONS Lic. NO <br /> IrENSE AND/OR 1 /- �— POULTRY RANCHES AND KENNELS <br /> BTRATION --� I Z MISCELLANEOUS SERVICE% ENVIRONMENQq <br /> I. .dER __.__.__..____. yl_. J r _PERMITS C� <br /> [Application Date _ Business/Name To Appear On Permit <br /> FI Type Permit/Service Requested:„//�r: ._-- e.,_ � cQ a — <br /> a Applicant Name _ _..__._.._ Z Address 4,//9/- <br /> Business <br /> ,/ -Business Telephone No. `jr/b Emergency Telephone No. <br /> .Property Location/Address- /& <br /> Property Owner 6(IV/4�� - <br /> LOperator's Name <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 ❑ 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 OUALITY ❑ 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 /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> F :ENNEL/Runways -- /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> 6. IT CONSULTATION FEE / r i(+rr�Z 7, 1-111" <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 Dale <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 A Received By July 31 <br /> BILLING REMITTANCE E REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> /I AMOUNT <br /> FEE <br /> LESS <br /> PRORATION C5 ) <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r�D _ <br /> % <br /> L—Re?cb�� <br /> y Date Ipt No. Permit No.o. <br /> Iss ate Mailed Delivered <br /> FIT—RETURN ALL COPIES TO: ENVINONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZEL.-ON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />