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- - Applications Will Be When Submitted Properly Completed. Be <br /> Sign The Application. <br /> APPLICATION so, I <br /> ENINEER'S ANDOR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> : <br /> AP r'ANT'S AND OR 4 <br /> C64TRACTOR AND/OR FOUR ESTABLISHMENTS, HOUSING IF VEHICLE INVOLVED, GIVE <br /> BROKER AND/OR PUBLIC POOLS,WATER SAMPLING Make __ <br /> ItENSE AND/OR R REAL ESTATE INSPECTIONS Lic-POULTRY RANCHNo. <br /> t. ES AND KENNELS - - <br /> ' iTRATION -- <br /> *.dER - MISCELLANEOUS SERVICES Reglst. No, - _- <br /> Color - <br /> .Type <br /> Date �a]LAppear On Permit <br /> �90 _ Business/Name To A _ jlf ,� oN <br /> fr <br /> Permit/Service Requested: _- - <br /> -I-' - <br /> �f -- - - -- _ <br /> � - <br /> Address C <br /> a APRlicant Name - <br /> Business Tete hone No. <br /> a - �- p —� _--�� -- Emergency Telephone No <br /> ', Property LacationJAddress 1��.tJ ,� -� - '� - <br /> Property Owner - - - <br /> Address , - - <br /> L Operator's Name <br /> 1. FOOD ESTABLISHMENTS - - Address _ - ---- - <br /> 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 <br /> ❑ ROADSIDE FOOD STAND 11 LIQUOR STORE C1 BAR ❑ BAKERY <br /> ❑ CONFECTIONARY STORE El FOO[) SALVAGER El FOOD DEMONSTRATION ITINERANT RESTAURANT <br /> ❑ FOOD VENDOR <br /> VENDING MACHINES/No. of _ <br /> ❑ FOOD CROP HARVESTING/No. <br /> of Field Employees ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING - <br /> ❑ HOTEL/MOTEL/No. of Units <br /> El MOBILE HOME PARK/No of Spaces CERTIFICATE OF OCCUPANCY <br /> 3. WATER QUALITY ❑ WATER AMPLE (Bacterial) 11 CHEMICAL <br /> 11 PUBLIC WATER SYSTEM OS URFACE 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 /> F '.ENNEL/Runways __ - /Animal Population No. _ <br /> No. of Confining Cages <br /> Sewage Disposal Method - --- <br /> Solid Waste Disposal Method - - - - - - - - - - - - - - — --_- <br /> Water Supply Source -- -- - - - - --__ <br /> Animal Waste Disposal Method <br /> 6, 0 CONSULTATION FEE - <br /> 7. ❑ PLAN CHECKING FEE <br /> S. REAL ESTATE <br /> REQUEST Water Well Inspection El Sample❑ Title Company - <br /> Sewage System Inspection ❑ Address <br /> Escrow Na. - - Tele. 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. <br /> APPLtCANT'S SIGNATURE X <br /> l - ------ - - - - - - Title- _ Date <br /> I FOR DEPARTMENT USE ONLY - - - - -- <br /> IIII Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE LJ EACH ❑ January I &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> ,r <br /> DATEDATE REMITTED AMOUNT DUE CHECKED <br /> r <br /> FEE AMOUNT <br /> — CID -- - 471D <br /> LESS �! — <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date — No — mi — — <br /> Pwt No. Issua _ _Veiled Mad Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />- 1601 E.HArELTON AVE.,P.O.BOK 2009 STOCKTON,CA 95201 <br />