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Applications Will Be Pr- sed When Submitted Property Completed. Be Su-To Sign The Application. <br /> 1111"I'll+ APPLICATION U-1++ <br /> ENVIRONMENTAL HEALTH PERMIT/SERVIZES <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 AND/OR REAL ESTATE INSPECTIONS LIC. No. <br /> Ir'FNSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No.___ <br /> I. AER Color <br /> Application Date Business/Name To Appear On Permit <br /> Type Permit/Service ested' <br /> i Applicant Name —__ _ —. Address_4.9, <br /> —_.._—______ _ __ BusinessTelergency Telephone No. <br /> SProperty Location/Address p J <br /> Property Owner _ __ 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. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacteria]) ❑ 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 /> Wa r upply Source Animal Waste Disposal Method <br /> b. CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE <br /> B. REAL ESTATE <br /> REQUEST' Water Well Inspection 11 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. <br /> APPLICANT'S SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY 1 <br /> _ I <br /> Fee Is Due: C3 ANNUALLY ❑ PER UNIT C1 PER SITE 11 EACH ❑ January 1 6 Recei d By January 11 ❑ July 1 3 Received By July 31 <br /> BILLING REMITTANCE f REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> �y '/ AMOUNT <br /> FEE SQ /, p — <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by D to Receipt No Permit No issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 445 N. San Joaquin St_ P.O.Sol Z= STOCKTON,CA 25201 <br />