Laserfiche WebLink
Applications Will Be Ped When Submitted Properly Completed. Be #fo Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> IF VEHICLE INVOLVED, GIVE <br /> ENGINEER'S AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> APPLICANT'S AND/OR Make .-- <br /> CONTRACTOR AND/OR PUBLIC POOLS, SPECTWATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS � 0. <br /> - <br /> BROKER <br /> OKER AND/OR POULTRY RANCHES AND KENNELS ogi t 14 <br /> ;SEA ND/ MISCELLANEOUS SERVICES <br /> I. .dER ---- -- -- - - // ^ <br /> Application Date0 l 1 Busine s/Name To Appear On Permit - — <br /> Type Perit/Service R quested: _1__�!_S�e� <br /> m <br /> a Applicant Name .__�HI /� ' �1 -- Address <br /> Business Telephone No - - Teleone No.1 <br /> aProperty Location/Address --7 Q J + <br /> a <br /> Property Owner Add&,, <br /> � <br /> Operator's Name - _�(-'LLrrt?'--�' ---- ----- `---_ 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 REP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees ---ALL APPLICANTS: Total Employees Including Operators - --- <br /> 2. HOUSING <br /> 13HOTEL/MOTEL/No. of Units —_- __ 11 CERTIFICATE OF OCCUPANCY <br /> 13 MOBILE HOME PARK/No. of Spaces <br /> 3. WATER OUALITY ❑ WATER SAMPLE (Bacterial) 13 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 /> Water,Su ly Source - _.� _ Animal Waste Disposal Method <br /> Q <br /> 6. CONSULTATION FEE <br /> T. ❑ PLAN CHECKING FEE <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection Sample C1 Title Company <br /> Sewage System Inspection ❑ Address __---__ .. ----- <br /> Tele. No. <br /> Escrow No. ------ -- 1---- <br /> Seller _ - ----. ----- - Seller Address -T <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 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> ---- - REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> T -3 _00/ �s . 9/21/90 <br /> � - - - <br /> FEE f <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date — Ruceipt No Permit No Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />