Laserfiche WebLink
--AppIlca1Imu.Wal.L@q rr-�s,st�L ( en Submitted Properly Completed. Be Surma To Sign The Application. <br /> APPLICATION <br /> E[ YIR_ONMENTAL HEALTH PERMIT/SERES <br /> APPOCN S AND!OR R IF VEHICLE INVOLVED,GIVE <br /> 4PP�ICANT'S AND/OR `3 p F000 ESTABLISHMENTS.HOUSING <br /> C'�NTRACTOR AND/OR; DEC 0 5 1�LT� PUBLIC POOLS.WATER SAMPLING Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> IrENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRA71oN MISCELLANEOUS SERVICES Regist. No. <br /> I. .BERV Color <br /> � . Ti ' ,,.sem <br /> ± y <br /> (Application Date _ Bu ess/N To A—.1,O Permit <br /> o Type Permit/Service Re ested: <br /> i Applicant N q ��'/ Zidress <br /> a9� -� usiness Telephone No. �l9�y�S—3D f'SL Emergency Telephone No. <br /> `Property Locati n/Addres �yU �j1JO�r/s��`JOrr <br /> cProperty Owner G. 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. <br /> ❑ <br /> HOTEL/MOTEL/No.Oof 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 /> .ENNEL/Runways /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply SourceAnimal Paste Dispos I Method <br /> 6. CONSULTATION FE % d��f' <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 P.. Date <br /> FOR DEPARTMENT USE ONL , C- 11 ,E 1• <br /> Fee IS Due: El ANNUALLY El PER UNIT 13 PER SITE El EAC—H ElJanua 1 Received By 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE v ( AMOUNT DUE CHECKED <br /> ���� DATE REMIT��� AMOUNT_ <br /> FEE ,�D 3ESS 12/1/88 PE MFN7AI <br /> `PRORATION <br /> � pEMAL71r;;A. r•. _L G;:�'�rI'LIL7 ,, <br /> _ f 0 PASTSUE ACCOUNTS 30 <br /> -B1 <br /> y h,; <br /> S�s <br /> Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> a r CANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ( 1601 E.HAZEL70N AVE.,P.O.Bos 2009 S70CKTON,CA 95201 <br /> AIM,I <br />