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Applications Will Be Psed When Submitted Properly Completed. B�S*o Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING 'MaK <br /> BROKER AND/OR REAL ESTATE INSPECTIONS LIC. N - <br /> JOENSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. --- . <br /> STRATION •-1-� MISCELLANEOUS SERVICES Color - <br /> I. .BER I--N L' LA <br /> f Application Date Business/Name To Appear On Permit —-------- - ---------- - -- <br /> vel Type Permit/Service Requested: ,�'� - _-- - <br /> i Applicant Name W A L t D G N 1 ) �^ F IZ1 1� Address --- <br /> u V.�Ec} �,C.CYIMP.E� 1 Business T lephone No. -. - Emergency Telephone No. - <br /> Property Location/Address L-A O W A�- 1 17 - - - - <br /> iProperty Owner _T aEI CAC It(1'�CAt Ot e-P_ QL-g- Address O, ��- AS <br /> -(Operator's Name 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 <br /> ❑ 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/MOTEUNO. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY ❑ 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 /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> r :ENNEL/Runways /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method -- <br /> Solid Waste Disposal Method - <br /> Waterr SuS ly Source Animal Waste Disposal Method <br /> B. 1� CONSULTATION FEE 3- r e !� F c, t , c -- _- <br /> T. ❑ .PLAN CHECKING FEE VA 1 <br /> B. 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 IF Received By January 31 ❑ July 1 8 Received By July 51 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> ('T AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLDs VtNALI 57pL-1ED TO PA§T DUE ACC UNTS 3G <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> Received by Dale Receipt No. Permil No. Issuance Dale Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE„P.O.Box 200 STOCKTON,CA 95201- <br />