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A <br />ENGINEER'S AND/OR <br />APPLICANT'S AND/OR <br />CONTRACTOR AND/OR <br />BROKER AND/OR <br />.IrFNSE AND/OR <br />3TRATION <br />I. r3ER <br />Applications Will Be cessed When Submitted Properly Completed. Be ' -re To Sign The Application. <br />APRUCA T ION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />FOOD ESTABLISHMENTS. HOUSING <br />PUBLIC POOLS, WATER SAMPLING <br />REAL ESTATE INSPECTIONS <br />POULTRY RANCHES AND KENNELS <br />MISCELLANEOUS SERVICES <br />IF VEHICLE INVOLVED, GIVE <br />Make <br />Lic. No. <br />Regist. No. <br />Color --- <br />Application <br />Application Date C - Busins/Name To Appeal01-2Per /m/it�_ ___ <br />wType Permit/Service Requested: - cl/!'moi l <br />I- <br />aApplicantName 7-5 54P%4211C eAA-1 — Address Qr_� -�i.Z <br />a� G Bu i ess Teleph ne No1�' _r1� 1� _ Emergency Telephone No. <br />OR Property Location/AcLdr�s/ / h. <br />Property Owner __-`�/v�VV j� Address <br />Operator's 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 PAY <br />❑ 7. <br />PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER Rece, VED <br />NO. OF PUBLIC SERVED (Connections) J�nv <br />4. RECREATIONAL HEALTH 11 SWIMMING POOL ❑ SPA 1:1 WADING POOL ❑ NATURAL BATNFP016 PLA CIF988 <br />5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br />ENNEL/Runways __ -__ /Animal Population No. -___ ..__ No. of Confining Cage ON <br />Sewage Disposal Method - . - - - -- All-r1c <br />Solid Waste Disposal Method — -- GES - <br />Water Supply Sourcei �nim�al,,Waste Disp I Method <br />6. R: CONSULTATION FEE _ / / "n MT- - <br />7. 13 PLAN CHECKING FEE <br />8. REAL ESTATE <br />REQUEST: Water Well Inspection C3 Sample Title Company <br />Sewage System Inspection ❑ Address Tele. No. <br />Escrow No. -- - - <br />Seller <br />Telephone No. <br />Service Request For Date <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: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & Received By January 31 ❑ July 1 & Received By July 31 <br />REMIT <br />BASE <br />EXPLANATION BILLING <br />REMITTANCE <br />$ <br />AMOUNT DUE CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEE <br />LESS <br />/,ZS <br />30 <br />PRORATION <br />_ _ <br />ACCOUNTS <br />PLUS <br />PENALI:TEJ <br />Al ,._ , .i <br />PENALTYDAYS <br />Y.0 <br />AIL. <br />OTHER <br />FRCM <br />OTHER <br />ReceivIiIiiby Date Receipt No. Permit No. Issuance Date Mailed Delivered <br />wen...... .. 41FAI TM PF9kYIT/1LFRV1[`FC 1801 F. NA7FLT93N AVF-- P.0- Rei 2009 STOCKTON- CA 95201 <br />