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` Applications Will Be Pr sed When Submitted Properly Completed. Be 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 IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lie. <br /> IrENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES to. <br /> I. aERr✓ � <br /> Color <br /> Application Date Business/Name To Appear On Permit _ <br /> .Type Permit/Service Requested: _ <br /> uApplicant Name �A�D A/ _FNSI jL_� <br /> ;�I �— Address � Qi <br /> a—uY r�yness Telqphone No. Emergency Telephone No. <br /> Q Property Location/Address tao _ ---1—y g41yyr 4Q <br /> a Property Owner ��re.-_.(_._._ _(L4 �- f hE iL Gd"Address <br /> L 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 ❑ 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 <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 /> f :ENNEL/Runways /Animal Papulation No. No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water S4pf ly Source Animal Waste Disposal yethod <br /> 6. VCONSULTATION FEE _ _ G Gtr <br /> 7. ❑ PLAN CHECKING FEE d <br /> B. REAL ESTATE <br /> REQUEST: Water Welt 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 /> 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 Dale <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 IT Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT_ <br /> FEE $105.00 3 hrsr -2112190 $105.00 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTYP.. ---—_WILL BEA PLIEDTOPA_T'D,IA ACC__UNTS. 4 <br /> OTHER DAYS FROM BILLINGDATE, <br /> OTHER <br /> Recelved by Date . <br /> I Prima No lss3We Data Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM IT/SERVICE S 1.601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />