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+ Applications Will Be Vroc'^ ed When Submitted Properly Completed. Be Sure--i Sign The Application. <br /> ' { - APPLICATION ..� <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR VEHICLE INVOLVEbVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING IF VEVE <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS ., ;a k; <br /> O <br /> I 5 AND/OR POULTRY RANCHES AND KENNELS5T"No� <br /> ATION -- MISCELLANEOUS SERVICES �..='- <br /> I. ER <br /> ------- COIOf <br /> (Application Date _ Business a ��/��o�A ea�rn O�n Per tt T �-l�.�-I' <br /> FType Permit/Service qu ted — .(/ _ �7®_r leo,- - 1Lr� <br /> uApplicant Name �gAddress_/_//_ <br /> d Bunn/�ss�Tele�jh e N 1l>�`� � t/f�-1I E ergency Telephone No. <br /> Property Location/Address.._ �11N-�l .I'A�,l_� <br /> iProperty Owner�� (►4A� _ Address <br /> -L Operator's Name �urL 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 (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 /> F 'ECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> I'`�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 Methoci <br /> C <br /> 6. CONSULTATION FEF t QQl1 J � �at4 _ n <br /> T. ❑ PLAN CHECKING FEE �i- <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 Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE f <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT_ <br /> FEE L� 88 <br /> LESS <br /> PRORATION <br /> `LUS <br /> �_ENALTYI <br /> PENALTIES <br /> OTHER DATE. <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1.601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON.CA 95201 <br />