Laserfiche WebLink
C�C PR ,Applications Will Be P sed When Submitted Properly Completed. Be $&To Sign The Application. F r� <br /> APPLICATION it' RKEIV <br /> 05002-f ENVIRONMENTAL HEALTH PERMIT/SERVICES V ED <br /> ENGINEERS AND/OR ///'''��� IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR CC�F_C_K. F000 ESTABLISHMENTS,HOUSING D ,(p/ Mak <br /> AONTRACTOR AND/OR PUBLIC POOLS.'NATER SAMPLING 1_yg`7%�`UL n. IST—O'er <br /> BROKER AND/OR �&�/ REAL ESTATE INSPECTIONS Lic. NO. ---— <br /> � IrFNSE AND/OR POULTRY RANCHES AND KENNELS ,p�gI <br /> I' STRATION MISCELLANEOUS SERVICES HAiiG�LLLNNN777111rrr A%GC _ <br /> 1. .SEA ___._- GO `tu- <br /> (Application Date—3 ZI q _ Business/Name To Appear On Permit ' ' S.�r �.�5 +��I✓ t'�'� �mpa"( <br /> n I fov;rw t,J-tJ�k J <br /> u,Type Permit/Servic R�equ�ested:-rte cu" .Q.�4 ------�. Z23 VPr1 iG�a- Ln, . Sul'L`3(Tj <br /> iApplicant Name �� --- Address <br /> Business Telephone No. — Emergency Telephone No. <br /> a Property Location/Address <br /> ISO tU 'S'���'r �"� r& <br /> `Property Owner _ Address <br /> j 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 /> 11 PUBLIC WATER SYSTEM 11 SURFACE WATER SUPPLY 13 WATER HAULER 007918 <br /> NO. OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds — - 3 <br /> r :ENNEL/Runways _._ . /Animal Population No. No..of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Su Source _ Animal Waste Disposal Method <br /> 6. CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE <br /> 6. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ Sample❑ 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 rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X Title Date— <br /> FOR <br /> ate 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 EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT_ <br /> FEE 35,oa ,S 4/5/89 5,25U <br /> LESS <br /> PRORATION - - <br /> PLUS <br /> PENALTY-' y[OTHER v ' 5 - f1 yI pnry <br /> ly <br /> TIES ILL BE APPLI D TO PAST D <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />