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Applications Will Be Pr ed When Submitted ProperlCo pleted. Be S Sign The Application. <br /> r ig APPLICATION <br /> ' ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> tNGINEER'S`AND/OR IF VEHICLE INVOLVED, GIVE <br /> ' APPLJ(;ANT'S ANO/OR FOOD ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. _ <br /> i+'FNSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TFIA71ON MISCELLANEOUS SERVICES g <br /> I. AEH — - ----- - Color <br /> Application Date � Business/Name To Appear On Permit <br /> oType Permit/Service Requested: _ <br /> a A plicant Name Go co&I L) Address <br /> aBusiness Telephone No. Emergency Telephone No. <br /> a Property Location/Address tiJ <br /> `Property Owner- 0-CRL _ Address <br /> -Operator's Name —� t�T tfJe,2 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 ❑ 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 /> rt <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 /> 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 Met o E <br /> C k CONSULTATION FEE — _-- �.� ��s� <br /> 7. 13 PLAN CHECKING FEE <br /> B. REAL ESTATE 1989 <br /> REQUEST: Water Well Inspection[] Sample❑ Title Company SAN JOAO(, <br /> Sewage System Inspection ❑ Address — PUBLIC� NF A �.-� 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 a plication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,and rule ation an Joaqui I Health District. <br /> APPLICANT'S SIGNATURE X Title !Iii CeQsgce< Date kl l u l <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 A Received By July 31 <br /> BILLING REMITTANCE E REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE _ DATE REMITTED <br /> 11/21/ 39 <br /> q �j /Jp A NT <br /> 11 <br /> FEE st r `i�"-'ru G 1 O <br /> LESS <br /> PRORATION <br /> PLUS - <br /> PENALTY <br /> OTHER --3�'° = I UNo 4 DAYS F TO PAST UEACCOUN 30 <br /> OTHER <br /> 1 991S__ <br /> Received by ate ipi No Permit No IssDate Mailed^ Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIR MENTAL HEALTH P@RMITl5ERYICES 1601 E.HAZ LTON AVE.,P.O.Box 2009 STOCKTON,CA 95261 <br />