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Applications Will Be Pro ` APPLICATION <br /> When Submitted Properly Completed. Be Sur o Sign The Application. <br /> ENVIRONMENTAL HEALTH PERMIT/SERV I S IF VEHICLE INVOLVED, GIVE <br /> ENGINEER'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make — — — — -- <br /> APPUCANT'S AND/OR PUBLIC POOLS,WATER SAMPLING Lic. No. -- — - <br /> CONTRACTOR AND/OR REAL ESTATE INSPECTIONS <br /> BROKER AND/OR POULTRY RANCHES AND KENNELS Regist. N0. - - - - <br /> irENSE AND/OR MISCELLANEOUS SERVICES Color - <br /> 3TRATION <br /> I, ,dER - <br /> Business/Name To Appear On Permit <br /> 1 Application Date <br /> Type Permit!Service Requested: t' <br /> ilCPl <br /> Address <br /> 4 Applicant Name 1 a'L i 1 Coast t Pro�� Emergency Telephone No. <br /> Cad j.ft�rltia Business Telephone No. o <br /> .Property Location/Address Paelf c <br /> Address <br /> aProperty Owner _ - Address ? <br /> Operator's Name .Fad © � <br /> Total Building Sq. Footage 'Restaurant, Maximum Seating Capacity <br /> 1, FOOD ESTABLISHMENTS D MARKET WHOLESALE ❑ MEAT MARKET <br /> 11 RESTAURANT <br /> FOO <br /> RESTAURANT FOOD MARKET RETAIL ® ICE PLANT ❑ BAKERY <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ITINERANT RESTAURANT <br /> ❑ <br /> ❑ ROADSIDE FOOD STAND 13LIQUOR STORE BAR <br /> ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER 11 VENDING VEHICLE <br /> ❑ MOBILE FOOD PREP. UNIT <br /> ❑ VENDING MACHINES/No. of --11 FOOD FOOD CROP HARVESTING/No. of Field Employees - - -ALL APPLICANTS: Total Employees Including Operators- - - <br /> 2. HOUSING ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ HOTEL/MOTEL/No. of Units - <br /> ❑ MOBILE HOME PARK/No. of Spaces - 13CHEMICAL <br /> 3. WATER QUALITY 11 WATER SAMPLE (Bacterial) ❑ WATER HAULER <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY <br /> NO. OF PUBLIC SERVED (Connections) - - - - - NATURAL BATHING PLACE <br /> 4. RECREATIONAL HEALTH <br /> [:1 SWIMMING POOL 11 SPA ❑ WADING POOL <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds - <br /> No,of Confining Cages <br /> ENNEL!'Runways /Animal Population No. - <br /> Sewage Disposal Method - - --- <br /> Solid Waste Disposal Method - Animal Waste Disposal Method - - <br /> Water Supply Source < - <br /> 6. ❑ CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE PrOP <br /> a. REAL ESTATE - <br /> ❑ <br /> REQUEST: Water Well Inspection❑ Sample <br /> Title Company Tele. No. <br /> Address - <br /> Sewage System Inspection <br /> Escrow No. - - <br /> Seller Address_ -- <br /> SelYer - - - <br /> Seller 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 /> _ Title _ --- _ Date_ <br /> APPLICANT'S SIGNATURE X -- - - - <br /> FOR DEPARTMENT USE ONLY <br /> REMIT <br /> 73, <br /> BILLING REMITTANCE <br /> Fee is Due. ❑ ANNUALLY PER UNIT ❑ PER SITE El EACH ❑ January 1 &Receive��d By January 31 [3 July i &Received By July <br /> AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED — — AMOUNT <br /> FEE — <br /> LESS — <br /> PRORATION — <br /> PLUS — <br /> PENALTY — <br /> OTHER <br /> OTHER G <br /> Issuance Date Mailed Delivered <br /> Receipt No Permit No <br /> Date <br /> Redid by 1601 E.HAZELTON AYE.,PA.Box 2009 STOCKTON,GA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />