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Applications Will Be Prssed When Submitted Properly Completed. Be Suria To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICE5 <br /> - IF VEHICLE INVOLVED, GIVE <br /> ENGINEER'S AND/OR FOOD ESTABLISHMENTS.HOUSING <br /> t APPLICANT'S AND/OR Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> .ir'ENSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> STRATION MISCELLANEOUS SERVICES <br /> Color - <br /> i. AER _ <br /> [Application Date Business/Name To Appear On Permit - - - <br /> I.- Permit/Sere Requeste <br /> UApplicant Name ��- �A Address <br /> Business Telephone No. Emergency Telephone No. <br /> J <br /> aProperty Location/Address <br /> -_j Property Owner Address <br /> I <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 ❑ 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 --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 /> ,ENNEL/Runways ____ /Animal Population No. No. of Confining Cages <br /> Sewage Disposa6 Method <br /> Solid Waste Disposal Method <br /> Water Source Animal Waste Disposal Method <br /> 5. CONSULTATION F€E W6 !7�L IY, r <br /> 1. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE ,�1 <br /> REQUEST: Water Well Inspection Sample[] Title Co <br /> Sewage System inspection ❑ Addr ��.d_� Tele. No. <br /> Escrow No. <br /> Seller —_ S-11" r Addre <br /> Telephone No. _ Seller Agent Name - <br /> Service Request For 'Date <br /> I hereby certify that I have prepared this application and that ttitrk 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 &Received By J ary 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMO T DUE CHECKED <br /> DATE DATE REMIT D AMOUNT <br /> V { <br /> FEE ✓ <br /> PRO 16N <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date ipt No Permit No. IsslWDate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVI NMENTAL 14EALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Bop 2002 STOCKTON,CA 95291=J <br />