BILLING - Laserfiche WebLink

Home Browse Search

Applications Will ocessed When Submitted Properly Completed.4bure To Sign The Application. APPLICATION ENVIRONMENTAL HEALTH PERMIT/SERVICES ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make CCNTRACTOR ANDrOR PUBLIC POOLS.WATER SAMPLING BROKER AND/OR REAL ESTATE INSPECTIONS LIC No. -- IrrNSE AND/OR POULTRY RANCHES AND KENNELS Regist. No, 3TRATION MISCELLANEOUS SERVICES I, Color .aER ' I Application Date 1 �f _=( ._—� Business/Name To Appear On Permit .Type Permit/Service R�quuested:--J �__ Spet T1-' �Q a Applicant Name �' s✓ S -.--- Address.__. _ `-' J o N Telephone Business Tele 3 y7--_-�e ._ Emergency Tete one No. — .33CL p I -Properly Location/Address..,;Z� - -M-Ld,-4, rss -G- _ ��N�Property Owner-+. l�L1 —__-- — -- AdC-- � c- s- f �� -�i9- ! � L Operator's Name SQL —�.� Address 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE FOOD CROP HARVESTING/No. of Field Employees ALL APPLICANTS: Total Employees Including Operators-- 2. HOUSING ❑ HOTEL/MOTEL/No. of Units — ❑ CERTIFICATE OF OCCUPANCY ❑ MOBILE HOME PARK/No. of Spaces 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER NO. OF PUBLIC SERVED (Connections) -� 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds — F '.ENNEL/Runways _____ /Animal Population No. No. of Confining Cages Sewage Disposal Method — Solid Waste Disposal Method Wate_r,Suu ly Source _ Animal Waste Disposal Method 6. t�CONSULTATION FEE 7. 13 PLAN CHECKING FEE B. REAL ESTATE REQUEST: Water Well Inspection Sample0 Title Company Sewage System Inspection ❑ Address s Tele. No. Escrow No. --- Seller . Seller Address Telephone No, Seller Agent Name _ - Service Request For 'Date - - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. APPLICANT'S SIGNATURE X Title Date FOR DEPARTMENT USE ONLY Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July l d Received By Jury 31 REMIT BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE - LESS PRORATION PLUS PENALTY OTHER r OTHER ---— 11 Received ay Dale Ruceipl No Perms No Issuance Dale Malted Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITiSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95101