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Applications Will Be PIS sed When Submitted Properly Completed. Be SO Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> IF VEHICLE INVOLVED, GIVE <br /> ENGINEER'S AND/OR <br /> APPLICANT'S AND/OP F000 ESTABLISHMENTS.HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> ER AND/OR REAL ESTATE INSPECTIONS LIC. NO. - - ---- <br /> SE ANO/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TRATION MISCELLANEOUS SERVICES <br /> QOIOf <br /> I. AER <br /> r <br /> f Application Date � � Business/Name To Appear On Permi <br /> Im Type Permit/Service RequestLecd.:.5pf. - - ns 5T— <br /> iApplicant Name--�� >�!�N -+e✓/<<fNt�LK^ �/Address�� ° s� ��"�� <br /> u s� �. <br /> Business TelephonneNoo. _w g n y elephone o. <br /> it,t,Property Location/Address �5�.! <br /> ` © /�n+ /�/° S dress =/ Z S x. <br /> `Property Owner /�N , <br /> LOperalor's Name _ yv� ddress - <br /> 1. FOOD ESTABLISHMENTS / ' Total wilding Sq. Footage Restaurant, Maximum Seati 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 `�4eAxr <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 /> 0ECTOR CONTROL 11POULTRY 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 /> Water Supply Source ...—_ Animal Waste Dispo al Method <br /> 6. 12.CONSULTATK)N FEE I'D i✓I, �n Imo— I efiz V i S I <br /> T. C3 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 a Received By January 31 ❑ July 1 A Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCENREMITTED <br /> AMOUNT DUE CHECKED <br /> L <br /> DATEDATEDATE AMOUNT_ <br /> FEE e'� Iff I* ✓! UQ <br /> LESS l �� <br /> PRORATION <br /> PLUS <br /> PENALTY PFP.vr l -O II ^o <br /> I•Ji ',J L c� <br /> OTHER DAYS -aolm BiLury ` DAiL. <br /> OTHER <br /> Received by Date Receipt No, Pemnd No. Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box Was STOCKTON,CA 95201 <br />