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W7 <br /> Applications Will Be P sed When Submitted Properly Completed. Bela Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> • IF VEHICLE INVOLVED, GIVE <br /> ENGINEER'S AND/OR FOOD ESTABLISHMENTS.HOUSING <br /> APPLICANT'S AND/OR Make <br /> PUBLIC POOLS. WATERSPECT SAMPLING <br /> CONTRACTOR AND/OR <br /> REAL ESTATE INSPECTIONS Lic. No. <br /> BROKER AND/OR POULTRY RANCHES AND KENNELS <br /> Ir.ENSE AND�OR Reglst. No.- <br /> MISCELLANEOUS SERVICES <br /> 3TRATION - <br /> Color <br /> I, t3ER - - <br /> iApplication Date _ _ -__ usine s/Name To Appear On 'Permit 1.� 1✓ -- - <br /> ,*Type Permit/Service�yR�e,quested: <br /> a Applicant Namel�/y �[lL -Y1or\-- -- � Address <br /> �� �D Business Telep one NIq J5g ��— Emergency Telephone No. <br /> pp � - <br /> 0-Property Location/Address -- 96, _n <br /> -J'Property Owner _ -- --- --- --- - Address <br /> Address <br /> Operator'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 -_ 0 MOE3ILE FOOD PREP UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees -ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING/ <br /> ❑ HOTEL/MOTEL/No. of Units —_� El CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No, of Spaces <br /> 3. WATER QUALITY11WATER SAMPLE (Bacterial) C3 CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections)___ _ -- --- <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL 13 SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds _ <br /> .ENNEL/Runways _- _ _ /Animal Population No. __ No. of Confining Cages <br /> Sewage Disposal Method ---- - -- - <br /> Solid Waste Disposal Method <br /> _ Animal Waste Disposal Method <br /> Water Supply Source --- <br /> 6. ❑ CONSULTATION FEE e - <br /> 7. PLAN CHECKING FEE <br /> B. REAL ESTATE 40- <br /> Ckh14�'A/ <br /> REQUEST: Water Well inspection❑ Sample Title Company - <br /> Sewage System Inspection ❑ Address _ Tele. <br /> Escrow No. — - <br /> Seller Address <br /> Seller — <br /> Telephone No. Seller Agent Name _ /j✓t <br /> �;:,• Ems, _ <br /> Service Request For Date <br /> I hereby certify that I have prepared this application and that the work will be done in accordance wit San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANTS SIGNATURE 7( Title _ 6 � Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is t)Ue: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 $Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> A.� <br /> I? <br /> FEE (/ �y DATE r� REMITTED AMOUNT <br /> FE€ <br /> LESS + R ST DUE ACCO UNTS 30 <br /> PRORATION <br /> PLUS <br /> PENALTY J - - <br /> OTHER .5 _• a ,F1� <br /> OTHER V / <br /> Date Mailed Delivered <br /> Received by Date �ceipt No Permit No <br /> e <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTO N.CA 45201 <br />