Laserfiche WebLink
Applications Will Be PIs sed When Submitted Properly Completed. Be S To Sign The Application. <br /> 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 Lie. No. <br /> IrENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No.—_— —_ --_ <br /> I. .BER _. Color <br /> -Application Date—. y Business/Name To Appear On Permit <br /> .Type Permit/Service Requested--. --- <br /> `a Applicant Name – /Address egey 9/& <br /> – <br /> j _ Business Telephone Nogency Telephone No – - <br /> aPropertyLocation/Address .T1L-Q L-. _-_ Lt%r�-f✓ '� ( iti' _. _ <br /> j Property Owner ___ _—– _ Address – <br /> a <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 ❑ FOOD VENDOR 1 <br /> ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING��CLE�(;�� <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees – n\L\jil \\}U\ <br /> ALL APPLICANTS: Total Employees Including Operators _. <br /> 2. HOUSING pp <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCJ'a A 19pE� <br /> 11 MOBILE HOME PARK/No. of Spaces 1 <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> 11 PUBLIC <br /> OBLPUBL C SERVEDEConnectl ❑ <br /> ❑onsSURFACE WATER SUPPLY WATER HAULER <br /> NOCM M SCS���GES <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 /> WaterI/Su�,{�ly Source Ani al Waste Disposal Method <br /> 6. L ONSULTATION FEE L��y'd"` "� �-- <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 $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> G[/ AMOUNT <br /> FEE �./ I /t /e 00 35.01 <br /> LESS <br /> PRORATION <br /> PLUSPENALTIES /ILL BE APPI_1 D TO PAST D E ACCOUNTS 30 <br /> PENALTY <br /> r\ I <br /> OTHER - <br /> OTHER <br /> Received Ey DJ to ceint No Permit No Is Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box M09 STOCKTON,CA 95301 <br />