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Applications Will Be Processhen Submitted Property Completed. tae Sure TOn The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES IF VEHICLE INVOLVED, GIVE <br />,iNGINEER'S AND/OR FOOD ESTABLISHMENTS,HOUSING Or — <br /> ITRATION APPLICANT'S AND/OR PUBLIC Pool$.WATER SAMPLINGi�,CONTRACTOR AND/OR REAL ESTATE INSPECTIONSBROKER AND/OR POULTRY RANCHES ANO KENNELSeIr.FNSE AND10R MISCELLANEOUS SERVICES o <br /> 1. .BER <br /> f f $� Business/Name To Appear On Permit ._ - <br />`Application Date - - - .�- _ _ _ /� ,t� ()_ _`JTc ► <br /> a Type PerMit/Service R — <br /> Reequuested:-� —,d— - f Address ? 'W" I- <br /> GEF '-'+�"" ' <br /> i A plicanl Name Q-60 Emergency Telephone No. <br /> R�t�o� - Business Telephonne,No. _--.. - <br /> 4owjF _-TT <br /> 0.Property Location/Address- �1'- -- - - <br /> t� Address <br /> Property Owner_LNOC- Address -- —�--' --�-- -- <br />•LOperator's Name Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> 1. FOOD ESTABLISHMENTS Op MARKET WHOLESALE ❑ MEAT MARKET <br /> [IRESTAURANT0 FOOD MARKET RETAIL FOOD MARKET <br /> PLANT [3 BAKERY <br /> 0 FOOD PROCESSING PLANT ❑ COMMISSARY 0BAR ❑ ITINERANT RESTAURANT <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE 13 FOOD VENDOR <br /> 0 CONFECTIONARY STORE ❑ FOOD SALVAGER El FOOD DEMONSTRATION ❑ VENDING VEHICLE <br /> ❑ MOBILE FOOD PREP. UNIT <br /> • VENDING MACHINES/No. of - <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees <br /> ALL APPLICANTS: Total Employees including Operators—­­­ <br /> 2. <br /> perators ---^ _2. HOUSING ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ HOTEL/MOTEL/No. of Units � <br /> 0 MOBILE HOME PARK/No. of Spaces [] CHEMICAL <br /> 3. WATER QUALITY 11 WATER SAMPLE (Bacteria ❑ WATER HAULER <br /> 0 PUBLIC WATER SYSTEM ❑ SURFACE WATERS UPPLY <br /> NO. OF PUBLIC SERVED (Connections) ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 4. 'RECREATIONAL HEALTH ❑ SWIMMING POOL <br /> 5. VECTOR CONTROL 0 POULTRY FARM/Maximum No. Of Birds ---- Flo.of Confining Cages <br /> .ENNEL/Runways --•� /Aniral 'Population No. �� — - --- <br /> Sewage Disposal Method -- <br /> Solid Waste Disposal Method Animal Waste Disposal Method - - <br /> Water Supply Source - -- - <br /> 6. 9 CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE <br /> B. REAL ESTATE - <br /> Title Company -.--.. <br /> REQUEST: Water Well inspection 13 Sarm�e Tele. No. <br /> Address _�_----- ---- <br /> Sewage System Inspection <br /> Escrow No. �--_---- <br /> Seller Address ------.- -� <br /> Seller __. .-------�------ _ - - <br /> Seiler Agent Name <br /> Telephone No. ----- -- 'f —- <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 /> Title_ Date --- <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> REMIT <br /> Fee Is Due: ❑ ANNUALLY Q PER UNIT Q PER SITE ❑ EACH ❑ January 18 Received By.lanuary 31 � July 7 eG Received By July 3t <br /> BILLING REMITTANCE t AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> 50 <br /> 11�+21 8 r <br /> FEE —..- . ......--- <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY _ -PERALTIES- L BE-APPLI bfi© PASS' UEACCOUN _3') <br /> OTHER ' ' R��"i� G DAYS �Q B1L IN -D T€-- --`--,_ - <br /> i <br /> R Na—f�— Permit No OTHER <br /> Issuance vale Mailed Delivered <br /> Received by Date <br /> 7601 E.HA2ELTON AVE..P.O.gas 2909 STOCKTON CA <br /> ADVLICANT—RETURN ALL COPIES TO! ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />