Laserfiche WebLink
IFApplications Will Be Pr( .d When Submitted Properly Completed. Be Su 1 Sign The Application. <br /> s r APPLICATION -- <br /> ENVIRONMENTAL HEALTH PERMD <br /> ENGINEER'S AN IORAND/OR <br /> I VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/Ofl F000 ESTABLISHMENTS, BOBBIN u <br /> CONTRACTOR ANO/OR PUBLIC POOLS. WATER SAMPLING ke <br /> BROKER.AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> Ir1FNSE AND/OR POULTRY RANCHES AND KENNELS <br /> STRATION MISCELLANEOUS SERVICES Regist. No. <br /> I. .a ER 1 Color <br /> [Application Date }T�b—a9 Business/Name To Appear On Permit <br /> Type Permit/Serv''ic.e�RRegqu�uenst'e'd: <br /> i Applicant NameAddress-420 A) • SbyT1F1 1,i* - 1 U <br /> u <br /> o Business Telephone No. — Emergency Telephone No. <br /> .Property Location/Address— L <br /> iProperty Owner. •� IrJL _ Address <br /> -[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 /> 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 Supply Source -__ Animal Waste Disposal Method <br /> 6. CONSULTATION FEE 1L(P 'V <br /> 7. ❑ PLAN CHECKING FEE <br /> S. 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 /> 1 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 d Received By January 31 ❑ J eived By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> AMOU DUE HECKEO <br /> //YY�T� E(.// GATE DATE REMITTED AMOUNT_ <br /> FEE ^ ✓V .O Mzs <br /> LESS - - <br /> PRORATION I <br /> PLUS <br /> PENALTY <br /> OTHER 2. <br /> OTHER 3/20/%9--j- <br /> c,? 20 89 v <br /> Received by Date Receipt No. Permit No Issuance Data Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PEnMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.boa 20141 STOCKTON,CA 95201--- <br />