Laserfiche WebLink
/� Applications Will Be " z,-ssed When Submitted Properly Completed. Be Sage To Sign The Application. <br />// APPLICA T ION <br />C_ ENVIRONMENTAL HEALTH PERMIT/SERVIUES <br />ENGINEERS AND OR IF VEHICLE INVOLVED, GIVE <br />APPLICANTS AND OR FOOD ESTABLISHMENTS. HOUSING <br />--- -- - - <br />CONTRACTOR AND OR PUBLIC POOLS. WATER SAMPLING Make - - <br />BROKER AND OR REAL ESTATE INSPECTIONS LIC No. <br />Ir'ENSE AND OR POULTRY RANCHES AND KENNELS Reglst. N0. <br />S7RATION MISCELLANEOUS SERVICES---— -- -- <br />i. dER - - -- --- - --- Color — ----- ---- <br />Application Date -. __ ____---_- _ Busin s%Name To Appear On Permit <br />,,,Type Permit Service RequCested:—c%1Ti SeTJniC/1 �v✓�!- //�lGlf�_-'-�/TfcCQi% 11� _ <br />a Applicant Name j __ ✓j_�iNAi'JJ/% l -- —_ Address _�?�,_,�jc_zZs�� <br />J <br />Bu i ess Teleph ne No -GSL' ��� Emergency elephone No. — <br />'a Property Location; A dr S ._f <br />Property Owner __r _1�fi�%%',__ —__ _% Address <br />Operators 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 <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 QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL PAYAj <br />El PUBLIC WATER SYSTEM El SURFACE WATER SUPPLY 13 WATER HAULER RECEIVED <br />NO OF PUBLIC SERVED (Connections) J�(�v <br />4. RECREATIONAL HEALTH El SWIMMING POOL ❑ SPA 1:1 WADING POOL ElTH <br />NATURAL BAFPOfS PL�C�9 <br />5. VECTOR CONTROL El POULTRY FARM/Maximum No. of Birds — / 8� <br />r ENNEL/Runways __ - /Animal Population No. — No. of Confining Cagel$`�NM� <br />Sewage Disposal Method - — F� <br />Solid Waste Disposal Method _— <br />Water Supply Source <br />6. :8: CONSULTATION FEE <br />7. 11 PLAN CHECKING FEE <br />8. REAL ESTATE <br />REQUEST: Water Well Inspection 13 <br />Sewage System inspection <br />Escrow No. <br />Seller <br />Telephone No. <br />Service Request For Date <br />imal Waste Dispel Method <br />Sample ❑ Title Company <br />El Address Tele No <br />Seller Address — <br />Seller Agent Name <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 <br />Title <br />Date <br />FOR DEPARTMENT USE ONLY <br />Fee IS Due: El ANNUALLY ❑ PER UNIT El PER SITE El EACH ❑ January 1 8 Received By January 31 ❑ July 1 8 Received By July 31 <br />Recery by Date d No Permit No Issua <br />,..+, <br />APPLICANT—RETURN ALL COPIES TO: ENVIRGENTAL HEALTH PERMIT/SERVICES 1601 E. HAZL. <br />tte Mailed Delivered <br />N AVE., P.O. Box 2009 STOCKTON. CA <br />-- <br />REMIT <br />BASE <br />EXPLANATION <br />BILLING <br />REMITTANCE 3 <br />AMOUNT DUE CHECKED <br />D/A-�TE�-/ <br />DATE <br />REMITTED <br />AMOUNT <br />FEE/ <br />lU/ <br />LESS <br />30 <br />PRORATION <br />ACCOUNTS <br />PLUS <br />',,,,,4%4 <br />PENALTY <br />I ire_ <br />ATE, <br />OTHER <br />f' ' <br />OTHER <br />Recery by Date d No Permit No Issua <br />,..+, <br />APPLICANT—RETURN ALL COPIES TO: ENVIRGENTAL HEALTH PERMIT/SERVICES 1601 E. HAZL. <br />tte Mailed Delivered <br />N AVE., P.O. Box 2009 STOCKTON. CA <br />