Laserfiche WebLink
A <br /> Applications Will Be Proce� S <br /> When Submitted Properly Completed. Be Sure ign The Application. <br /> h. <br /> APPLICATION % <br /> ENVIRONMENTAL HEALTH ERMIT/SERVICES <br /> IF VEHICLE INVOLVED, GIVE <br /> ENGINEER'S AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> APPLICANT'S AND/OR PUBLIC POOLS.WATER SA PLING Make <br /> CONTRACTOR AND/OR REAL ESTATE INSPECTIONS LIC. No. <br /> BROKER AND/OR POULTRY RANCHES AND KENNELS <br /> WENSE AND/OR Regist. No. <br /> 3TRATION MISCELLANEOUS SERVICE - <br /> Color <br /> .BER <br /> �! Business/Name o Appear On Permi f F-�P.rzSTa a At- <br /> Application Date ' <br /> ,Type Permit/Service Requested: Sm lA o R K 5 rL <br /> 4Applicant Name <br /> o �S G 21 FXAdfre r11b SRT►.! � � STiItFC.& �kAI ..�S-1��CJ�' <br /> a Awtp d F 4 4 . �4� � a�J _ Business Telephone No.t 151 Emergency Te leeph a No. <br /> K v o GD tZ <br /> a <br /> Location/Address Property Locatio <br /> Property Owner w1�3vaa.O t� Vl�t�o r-, z-4 f Address _ I3b-7 S • YL'Y FL�1 0- Zo$ S`�.�K�'J r� <br /> X Addres <br /> 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 ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DE ONSTRATION ❑ 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 13 <br /> 11HOTEL/MOTEL/No. of Units CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY ❑ 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 /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water, SS ply Source Animal Waste Disposal Method <br /> 6. W CONSULTATION FEE s O _i1 + B L,►41►J �' �lL,� 3� 2�� {q a � <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST. Water Well Inspection SampleO 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 I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and Zand regulations of the San Joaquin Local Health District. <br /> SIGNATURE X' <br /> " Tit Datelzl� Ier— <br /> APPLICANT'S <br /> FOR DEPARTMENT USE iONL <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH 13 January 1 &Received By January 31 ❑ July 1 &Received By my 31 <br /> EMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT_ <br /> FEE 1Z- S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered <br /> STOCKTDN,CA <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Baa 2009 95201 <br />