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Applications Will Be Pro- lsed When Submitted Properly Completed, Be Sur- To Sign The Application. <br /> ,. <br /> APPLICATION <br /> � ENVIRONMENTAL HEALTH PERMIT/SERVIT,'ES <br /> 'ENGINEER'S AND/ORIF VEHICLE INVOLVED, GIVE <br /> it APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make - - <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> 1cENSE AND/OR POULTRY RANCHES AND KENNELS Regist. NO. <br /> 3TRATION MISCELLANEOUS SERVICES <br /> QDIDr <br /> I. .BER —nn --//JJQ 'A/ 7LQ� //�- <br /> (Application Date <br /> 6— Z V ` Business/Name To Appear On Permit I' �'' - `wUy-" <br /> FI Type Permit/Service Requested: <br /> i Applicant Name Address <br /> Business Telephone No. Emergency Telephone No. <br /> J <br /> 'Property Location/Address <br /> Property Owner Address <br /> LOperator'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 if ❑ 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 H FtVESTING/No.of Field Employees <br /> ALL APPLICANT Total Emplo}ees 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 /> S. VECTOR CONTROL ❑ POULTRY FARM/MaximMr¢*�No. of Birds <br /> /Animal all No.� No. of Confining Cages <br /> :ENNEL/Runways <br /> Sewage Disposal Method <br /> Y- <br /> Solid Waste Disposal Methob. <br /> Water Supply Source — Animal Waste Disposal Method <br /> 6. ONSULTATION FEE <br /> 7/�PLAN CHECKING FEE <br /> e. REAL ESTATE �/ <br /> REQUEST: Water Well InspectiorrL'Sr Sample 13 Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <br /> i' <br /> Escrow No. -- } <br /> Seller Seller Address <br /> TelOone NO. ' p Seller Agent Na" <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 rul and regulati n f th an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X yl Title �Y/W """'(�r�7,y� Date e—G'-7,,l9 <br /> -0r <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July/8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE E 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 Cate Receipt No, Permit No. Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa Z STOCKTON.CA 95Za <br />