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' Applications Will Be Pr---ssed When Submitted Property Completed. Be Su--To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINFER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLIC,4T'S AND/OR F000 ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOF1 AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> irFNSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TRATION MISCELLANEOUS SERVICES <br /> I. .AER Color <br /> Application Date - Business a o A ear On Per it — __,nType Permit/Service equalted: - I + �� � Q �� - <br /> `Applicant Name _ 4T-`�I-- '- — gA�d�dress .. !_ -dor <br /> _ Bus ne�ss Tel h e N !��` �. _ .�EJrpergency Telephone No. <br /> 4 roperty Location/Addre -�J�_ <br /> Wine y -� f <br /> Property Owner �- � - - �, Address <br /> -Operator's Name —.�S�YY� -...---.-. .- 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 —. —_ 1:1MOBILE FOOD PREP. UNIT 11VENDING VEHICLE <br /> 13FOOD 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) <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 Source Animal Waste DisposalMath <br /> 6. CONSULTATION FEE n <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection[] Sample Title Company <br /> Sewage System Inspection Cl 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 Titl %T Date <br /> FOR DEPARTMENT USmeMP Q <br /> Fee IS Due: C1 ANNUALLY ❑ PER UNIT El PER SITE El EAC _❑ January­1 ei % January 31 ❑ July 1 8 Received By July 31 <br /> BASE EXPLANATION BILLING REMITTAIyQ J $ AMOUNT DUE REMITCHECKED <br /> �'A DATE DATE R EIM AMOUNT <br /> FEE -- --- - -- ../NC! ' 12/1/88 G <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY- I-F t/1 IC.Tlr'S. --PASMJE ACCOUNTS 33 <br /> OTHER U"'1 5f-[I Opv BILLING r)A:-F <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />