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Applications Will Be Pr^Ssed When Submitted Properly Completed. Be Sr-,\To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> FJJGINEER'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 ANO/OR REAL ESTATE INSPECTIONS Lic. No. <br /> .IrENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. -- <br /> I. .8ER Color ___...._...._ <br /> Application Date Business/Name To Appear On Permit •I3.f I. lC(�i`l� ' =� __ <br /> Type Permit/Service Requested: L <br /> i Applicant Name C:iC moi. EZ-1 Address &� Qlf,1L? ,L:rn ' _ ^ _ C_ <br /> ( A Business Business Telephone No. Emergency Telephone No.(SEL) / / ..1.- <br /> aProperty Location/Address , :, <br /> Property Owner__ O1 2Q7, 5' 17-72'_i:• -___-.. Address P.O. ?' � :: _GC ', _ <br /> - <br /> LOperator's Name � ., <br /> - - — <br /> 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 ❑ ITINERAKQ F ESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD`VENOOR <br /> ❑ VENDING MACHINES/No. of _ _ _ __-_.._._.______ ❑ MOBILE FOOD PREP. UNIT ❑ V$NDING VEH#CLE/ <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators— ' <br /> 2. HOUSING f f <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPAN <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 /> _ _t <br /> 6. EONSULTATION FEE ...4)iZ it%!STE- I '�-k � <br /> 7. ❑ PLAN CHECKING FEE <br /> S. REAL ESTATE <br /> REQUEST: Water Well Inspection[] Sample❑ Title Company - <br /> Sewage System Inspection ❑ Address ---_ <br /> _._..----------..---.--._ 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, a d rules afiA re ations of the San Joaquin Local Hea District. . <br /> APPLICANT'S SIGNATURE X . ✓ Title ��� Date Z � P <br /> i <br /> 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 <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 /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />