Laserfiche WebLink
' Applications Will E3e Pro0d When Submitted Properly Completed. Be Sur0 Sign The Application. <br />' APPLICATION J`D 1 <br />ENGINEER'S AND/OH <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />APPLICAN"S AND/OR FOOD ESTABLISHMENTS, HOUSING IF VEHICLE INVOLVED, GIVE <br />CONTRACTOR AND/OR PUBLIC POOLS, WATER SAMPLING Make <br />BROKER AND/OR REAL ESTATE INSPECTIONS Li C. NO. <br />IrENSE AND/OR POULTRY RANCHES AND KENNELS <br />3TRATION MISCELLANEOUS SERVICES Regist. No. <br />I, .BER Color <br />[Application Date Aw Busin ss/Name To Appear On Permit 7 3�C' �� 12ui/ <br />i Type PermiVService Re ested: 1 <br />a Applicant Name -5- /sL. uL•_ Address %f <br />U �e <br />a Business Telephone NpEQS% Emergency Telephone No. <br />'a Property Location/Address �r <br />aProperty Owner $! — Address <br />Operator's Name 's Address <br />1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br />❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br />❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br />❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br />❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br />❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br />❑ FOOD CROP HARVESTING/No. of Field Employees <br />ALL APPLICANTS: Total Employees Including Operators <br />2. HOUSING yyy M p�►�I <br />❑ HOTEL/MOTEL/No. of Units — ❑ CERTIFICATE CPA E gUp'iLRC,L'_ D <br />11 MOBILE HOME PARK/No. of Spaces cL V C <br />3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br />11A ����h(1 <br />PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER NUV 4 19' B6 <br />NO. OF PUBLIC SERVED (Connections) .__. ... <br />4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ jINiWJAISyI MfNTI§LFb96LTR <br />5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds PERMITISERVICES <br />F :ENNEL/Runways -__ /Animal Population No. No. of Confining Cages <br />Sewage Disposal Method <br />Solid Waste Disposal Method .._ <br />Water Supply Source Animal Waste Disposal Method <br />6. ❑ CONSULTATION FEE <br />7. ❑ PLAN CHECKING FEE <br />6. REAL ESTATE <br />REQUEST: Water Well Inspection[] Sample Title Company <br />Sewage System Inspection ❑ Address Tele. No. <br />Escrow No. <br />Seller ._.__._. Seller Address <br />Telephone No. __ Seller Agent Name <br />Service Request For Date <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br />ordinances, state laws and rules an re b E3� San Joaquin Local Health District. <br />APPLICANT'S SIGNATURE X Title �i�itf�.$' Date <br />FOR DEPARTMENT USE ONLY <br />Fee IS Due: ❑ ANNUALLY ❑ PER UNIT I—i PFP CITE n ­ _ n ,__..___....___.. <br />Received by Date Receipi No. Per.0 No. Issuance Date Mailed Delivered <br />APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE., P.O. So. 2009 STOCKTON, CA 95201— <br />- --- - <br />Py Hwy JI <br />BASE <br />EXPLANATION <br />BILLING <br />REMITTANCE E <br />REMIT <br />DATE <br />DATE REMITTED <br />AMOUNTDUE <br />CHECKED <br />AMOUNT <br />FEE__— <br />LESS---- <br />PRORATION <br />PLUS <br />-- <br />PENALTY <br />OTHER <br />— -- <br />OTHER <br />Received by Date Receipi No. Per.0 No. Issuance Date Mailed Delivered <br />APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE., P.O. So. 2009 STOCKTON, CA 95201— <br />