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Applications Will Be Pro, -ssed When Submitted Property Completed. Be Si, %To Sign The Application. <br /> APPLICATION <br /> NVIRONMENTAL HEALTH PERMIT/SERVTffES <br /> IF VEHICLE INVOLVED, GIVE <br /> ENGINEERS AND/OR FOOD <br /> r APPLICANT'S AND/OR PURL ESTABLISHMENTS.HOUSING Make -- - <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Li C. NO. - <br /> 1rENSE AND/OR POULTRY RANCHES AND KENNELS Reglst. No. <br /> 3TRATION MISCELLANEOUS SERVICES <br /> QDIDr <br /> I, .dER <br /> [Application Date A.2 j3 ✓r' 4 -"�"`^�Business/Name To Appear On Permit " k <br /> FI R <br /> Type Permit/Service -quested: <br /> i Applicant Name Address <br /> Business Telephone No. Emergency Telephone No. <br /> J <br /> A.Property Location/AQdress <br /> Property Owner_ Address <br /> Operator's Name _ Address <br /> 1. FOOD ESTAVLISHMENTS 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 /> 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 /> NSULTA710N FEE <br /> PLAN CHECKING FEE <br /> 8. R AL ESTATE <br /> REQUEST: Water Well Inspectiowv Sample 13 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, a rule and regulati n f ih an Joaquin Local Health District. 7 <br /> APPLICANT'S SIGNATURE X ` Y� Title If <br /> � 7�Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Receive i By January 31 ❑ July 1 a 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 /eel E.HAZELTON AVE.,P.O.Bos 1889 STOCKTON,CA 95181 <br />