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Applications WHI be ProcWhen Submitted Properly Complete U. Ue Sure Lsyn the Apphca Run. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED,GIVE <br /> A►►LICANTS AND/OR YOKO ESTABLISHMENTS,MOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic.NO. <br /> (CENSE AND/OR POULTRY RANCHES AMO KENNELS Regist. No. <br /> RUE&STRATION MISCELLANEOUS SERVICES <br /> NUMMA p ►/C�olor�/►,',t <br /> f Application Date d Business/Name To Appear On Permit � Jti�2���"— W� �_ <br /> w Type Permit/Servi Requested: 4r 110A <br /> A ' ant Nar11e Address <br /> sinesg Tplanhona,IN Emer a cy Telephone No. <br /> Property Location/ d re <br /> .�. ena <br /> Property Owne Address -�• L <br /> t Operator's Name Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. F tage 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 <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 DUALITY ❑ 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 /> 0 KENNEVRunways /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. ❑ CONSULTATION FEE -- <br /> 7. A PLAN CHECKING FEE <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection Sampler] Title Company <br /> Sewage System Inspection ❑ Address — ____ .. -_____. ___Tele. No. <br /> Escrow No. -- --- - - - <br /> Seller ___... ____ Seller Address <br /> Telephone No. __—_ Seller Agent Name <br /> Service Request For Date - -------- - <br /> I hereby certify that 1 spared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state I s.an 6san reguationAot the Sen J aquin Local Health District. !1 <br /> APPLICANT'S SIGNATURE ._ _. -_ Title .____.—._.____--._ ...__. Date-l-t __-_ _. <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I A Received By January 31 ❑ July 1 A Rec8lYed By July 31 <br /> REMIT <br /> BASE EXPLANATION r BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> ( DATE DATE REMITTED AMOUNT <br /> FEE ` ♦//1'A. A 7?1 l/y �_ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> - 3'�d' - --- -- -- - <br /> H. red by Dale Rempl No Permd No Issuance a Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES INN E.NAZELTON AVE.,P.O.Sor WN STOCKTON.CA 95201 <br />