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Applications Will Be Procen Submitted Properly Completed. Be Sure T i In The Application. <br /> 60 APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEERS AND/OR IF VEHICLE INVOLVED, GIVE <br /> APQLt6ANT,S AND/OR FOOD ESTABLISHMENTS. HOUSING Make <br /> CONTRACTOR AND40 PUBLIC POOLS,WATER SAMPLING -- - <br /> BROK9R AMD/OR' REAL ESTATE INSPECTIONS LIQ. N0. ---- _ <br /> IrENSE AND/OR ,y' POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. _ <br /> I. ,BER A` ~ .__ Color - —_ <br /> Q ` <br /> �f Application Date Business/Name To Appear On Permit,i Permit/Service Req�uested: /a n C H ii Cel <br /> i Applicant Name X G-N� eti�� �er. t.�nti� "ctut�'1.>c,tddressXaNit <br /> usiness Telephone No Or �-� Emergenty Telephone N <br /> aProperty Location/Address <br /> Property OwrtrAddress <br /> Operator'sName . 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 p. <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 OUALITY ❑ 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 /> r !ENNEL/Runways 14 /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method - <br /> Water Supply Source Animal Waste Disposal Method <br /> 6. I❑3 CONSULTATION FEE <br /> ,p / <br /> 7. .PLAN CHECKING FEE 3 T <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection[] Sample[] Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <br /> Escrow No. y, <br /> Seller___ Seller Address <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 dongIn accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health Didtrict. <br /> APPLICANT'S SIGNATUR X Title QCc.Sv��.K�� Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE - $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE OnK 3 �- <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> t <br /> OTHER <br /> OTHER <br /> L <br /> /AANT-RETUNN/A11 <br /> anteDate Mailed Delivered <br /> COPIES T0: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.MAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />