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Applications Will Be Processed WhenSUbmittearropeny aruN�o.�.,. ��• � p� <br /> APPLICATION a GENERAL <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES IF VEHICLE INVOLVED, GIVE <br /> .GINEI:R'S AN5,'OR FOOD ESTABLISHMENTS,ROUSING Make <br /> ,PPLICANT'S ANO/OR PUBLIC POOLS,WATER SAMPLING <br /> CONTRACTOR AND/OR REAL ESTATE INSPECTIONS � Lic. No. <br /> BROKER ANDlOR POULTRY RANCHES AND KENNELS Regist, No. <br /> LICENSE AND/OR MISCELLANEOUS SERVICES <br /> REGISTRATION Color <br /> NUMBER <br /> e <br /> -SZo�rN TAS for <br /> rApplication Date Business/Name To Appear On Permit <br /> Type Permit/Service Requested: <br /> i Applicant Name Q r s <br /> asL <br /> O Businer5s Telephone No. Emergency Telephgne No. <br /> a � � P t <br /> CL Property Location/Address <br /> d Property Owner Address <br /> a Address <br /> L Operator's Name <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 ❑ 13AR ❑ ITINERANT RESTAUFIANIl—,, <br /> ❑ CONFECTIONARY STORE 13 FOOD SALVAGER <br /> ❑ 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 p / <br /> G r... <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY fes` WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) '\J <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> ❑ KENNEL/Runways /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Animal Waste Disposal Method <br /> Water Supply Source <br /> 6. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT –. <br /> S. REAL ESTATE F <br /> REQUEST: Water Well.Inspection 1:3 Sample❑ Title Company <br /> Sewage System Inspection <br /> 11Address 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 I have prepared this app, ' and that the work will a done i accordance with San Joaquin County <br /> ordinances, state laws, and rules an regul I n o h San Joaquin Local alth Dist t. <br /> APPLICANT'S SIGNATURE X�' <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received REMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE s AMOUNT DUE CHECKED / <br /> • DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 6v4�16 AA <br /> ceived by <br /> Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES <br /> 1801 E.HAZELTON AVE.,P.O.Bo:2009 STOCKTON,CA 9520 <br />