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Applications Will Be Pdosed 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 /> APPLICANTS AND/OR FOOD ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lie. No. -.--. <br /> Icr_NSE AND/OR POULTRY RANCHES AND KENNELS Regist No <br /> STRIATION MISCELLANEOUS SERVICES <br /> Color -- <br /> I, .AER <br /> Application Date �,'----2- - Business/Name To Appear On Permit -.- -- --- <br /> ,nType Permit/Service Re uested: -- <br /> LINJ DjC� I _ ` ,!►� � �_ Address <br /> � <br /> a Applicant Name I <br /> L..�_ 1� Business Telprphone No. Emergency Telephone No. <br /> SI��Cn I� c_ J�Laj U L <br /> '(Property Location/Address. -- <br /> aProperty Owner .._ Address - - <br /> -L 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 11 FOOD DEMONSTRATION ❑ FOOD VENDOR' <br /> 11 VENDING MACHINES/No. of _ 11 MOBILE FOOD PREP. UNIT 11 VENDING <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> �gaa <br /> 2. HOUSING 4 <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCU CYO``" y ij\A <br /> 11 MOBILE HOME / o ❑ M )tr`(etS <br /> WATER3. UA11 WATER <br /> aCHEMICAL EN � r <br /> ❑ PUBLIC WATER SYSTEM SURFACE WATER ❑ WATER HAULER pE <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 _ Animal Waste Disposal Method - _ ----- <br /> 6. CONSULTATION FEE - <br /> T. ❑ .PLAN CHECKING FEE - <br /> 6. REAL ESTATE <br /> REQUEST: Water Well Inspection El 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 S Received By January 31 ❑ July 1 8 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 _ . ..-.. .. <br /> PLUS L-I <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date ceipt No. PerNo. Iss .Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZEL ON AVE.,P.O.809 21109 STOCKTON,CA 95201 <br />