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Applications Will Be Prsed When Submitted Properly Completed. Be STo Sign The Application. <br /> 41APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEERS AND OH IF VEHICLE INVOLVED, GIVE <br /> APPLICANT S AND;OH FOOD ESTABLISHMENTS.HOUSING Make <br /> CON IHAC[OR ANU�UH PUBLIC PUULS.WATER SAMPLING <br /> JOER AND/OR HEAL ESTATE INSPECTIONS Llc. No. . . . <br /> NSE AND,OH POULTRY RANCHES AND KENNELS Reg i51. No. <br /> i TRATION MISCELLANEOUS SERVICES <br /> I. dLH Color <br /> Application Date �I l 1 I<6"1. -_ Business/Name To Appear On Permit I 1 (t i ( � ' i'C; 1.l L I �l v t 1. 0(_ <br /> vaType Permit/Seivlce Requested III(.,( k � ) LL.1. <br /> a Applicant Name 't �cl l' G L .a I I . .a 't r.( . L ... . Address -� s ! �, � '..i. , ,(lc <br /> -- <br /> I 2-CL'-J. Business Telephone Na Emergency Telephone No <br /> aProperty Location/Address <br /> d Property Owner ... _._ _ Address <br /> a <br /> I.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 <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) <br /> W/ECREATIONAL HEALTH C3 SWIMMING POOL ❑ SPA ❑ WADING POOL 11 NATURAL BATHING PLACE <br /> ECTOR 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 Su y Solace .__.. Animal Waste Disposal Method <br /> 6. LY CONSULTATION FEE ------slY� -l_. �. ,C .,.--------- - ---- <br /> 7. ❑ PLAN CHECKING FEE - - <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection Sample❑ Title Company <br /> Sewage System Inspection ❑ Address ____.._ ___._.___ _ ___.- __- ___Tele. Na._.___-.--._ -.___ <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 rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X _____..___.___._ ___. .._._________..._________ Title___.-_ ..______-___ — Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE— E REMIT <br /> BASE EXPLANATION AMOUNTDUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEL — <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER 1.J1 Sy. y/J' <br /> - <br /> OTHER <br /> Recurved ny Date Receipt NV Permit No Issuance Dale Mailed Debvere0 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT;SERVICES 1601 E.HAZELTON AVE. P.O.Box 2009 STOCKTON CA 95201 <br />