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Applications Will Be Pr -ssed When Submitted Properly Completed. Be Si To Sign The Application. <br /> ,�. APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'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 /> .IrFNSE ANO/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TRATION MISCELLANEOUS SERVICES g <br /> I. .BER -- Color <br /> 100 <br /> (Application Date lz-z3 - Business/Name To Appear On Permit <br /> t Type Permit/Servi Re a d: - - -- --- <br /> `Ap I ant ame -Address 21: b4 <br /> — Bus'jess Telephone No. Emergency Telephone No. <br /> 6 �Is,� roperty Location/ dre <br /> i roperty caner 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-- - 11-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) PAYMENT <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHINGRrACtE I V E D <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds JAN.ENNEL/Runways /Animal Population No. No. of Confining Cages JAN <br /> Sewage Disposal Method �NVIRC� nlr., <br /> Solid Waste Disposal Method -- N�€r r_ <br /> Wat r Supply Source _—_ Animal Waste Disposal Method Pr-,DAV11-'4 <br /> v rfCl� <br /> 6. CONSULTATION FEE ciT <br /> 7. PLAN CHECKING FEE <br /> 8. 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 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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> /► AMOUNT <br /> — <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY DAYS FROM BILLI G DATE. <br /> OTHER <br /> -- —T - —T— <br /> OTHER --• 112/27/88 ^rIYD <br /> RPPL CANT—RETURN ALL DateCOPIESTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E!HAZELTONtAVE.,P.O.Boxe 2009 STOCKTON,CA 95201 <br />