Laserfiche WebLink
Applications Will Be Prsed When Submitted Properly Completed. Be Syr To Sign The Application. <br /> APPLICATION <br /> N ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEEH'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS, HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS, WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> irENSE AND/OR POULTRY RANCHES AND KENNELS <br /> >TRATION _ MISCELLANEOUS SERVICES Regist. No. <br /> I . .BER Color <br /> [ Application Date �' % � �U Business/Name To Appear On Permit <br /> Type Permit/Service Requested: <br /> K � uFBLr) 52 so • Address sa/Uc � _ �tek - Ssc / � <br /> ` Ap licant ame , <br /> ::I � J�'E32 q' Business Telephone No, Emergency Telephone No. <br /> a Property Location/AddressW Cjtft7E3Z, W I ' /' �� <br /> Oy <br /> J Property Owner IV ! �— S Ma �2Q Address 737 W ' �AN `� Pi- LOperator'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, HOUING <br /> 11HOTES MOTEL/No. of Units 11CERTIFICATE OF OCCUPANCY P.� M v �.' O <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER DUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> 4.0. OF PUBLIC SERVED RECREATIONAL HEALTHnn ❑ ISWIMMING POOL 11SPA ❑ WADING POOL 11NATURAL BATHING PLAC NMENSPv SES <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds �\.k� \W \j 'S�� <br /> r :ENNEL/Runways /Animal Population No. No. of Confining Cages PE <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> 8, Ip' CONSULTATION FEE <br /> - 7. PLAN CHECKING FEE <br /> 8, REAL ESTATE <br /> REQUEST: Water Well Inspection [] SampleCl Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <br /> Escrow No, <br /> Seller Seller Addres <br /> Telephone No. . Seller Agent Nam _ <br /> Service Request For Date <br /> I hereby certify that I have prepared this application and that th work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and ias and regulations a San Joe u Local Health District, <br /> APPLICANT'S SIGNATURE X Title a0 Date L • 13 , 89 <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 6 Received By January 31 ❑ July 1 A Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED <br /> //��/� 'ry'yn AT (� AMOUNT <br /> FEE . Vv L 11_ , . D <br /> LESS Fi�l� _TIL'J WILL BE 1 <br /> PRORATION <br /> PLDs ROM' BIL LI G DATE , <br /> PENALTY /Iy) <br /> OTHER <br /> OTHER N212 sll/d /V�7�(J <br /> Received by D le Recelpl No- Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1.601 E. HA2ELTON AVE., P.O. Box 4009 STOCKTON, CA 95201 <br />