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Applications Will Be Processed When Submitted Properly Completed . Be Sure To Sign The Application , i <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/ SERVICES <br /> ENGINEERS AND/ OR IF VEHICLE INVOLVED , GIVE <br /> APPLICANTS AND/ OR FOOD ESTABLISHMENTS, HOUSING Make — _ <br /> CONTRACTOR AND/OR PUBLIC POOLS, WATER SAMPLING -- <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic . No . <br /> DENSE AND/ OR POULTRY RANCHES AND KENNELS Regist , No . - <br /> 3TRATION MISCELLANEOUS SERVICES g - -------- -- <br /> I . . BER . . . - - - - - - - - - . -- - . . . _ . Color <br /> Application Date _ .3 ^ L_� 1 Business/ Name To Appear On Permit <br /> w Type Permit / Service eque t <br /> 7 <br /> a Applicant Name .__ __ __— __ _ _ Addresd J S - <br /> U __ <br /> Business Telephone o . _ A- I <br /> —_..— _ mergency Telephone Nom e r ' S- 13 ' �Y3 <br /> aProperty Location/A d�es •- � ^- _ _� _ <br /> J Property Owner <br /> tr mac- <br /> perator' s Name _ _._.__ _ __ _ _. _. . Address <br /> 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 IJ LIQUOR STORE El 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 i <br /> ❑ HOTEL/ MOTEL/No . of Units ❑ CERTIFICATE OF OCCUPANCY II <br /> ❑ MOBILE HOME PARK/ No . of Spaces I <br /> 3 . WATER QUALITY ❑ WATER SAMPLE ( Bacterial ) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER u <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 __ _ _ r _ /Animal Population No . — No . of Conflning Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method - <br /> Water-& y OUrce Animal Waste Dispos Method <br /> 6 . CONSULTATION FEE <br /> - 7 : ❑ PLAN CHECKING FEE <br /> Be REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample ❑ Title Company _ <br /> ASewage System Inspection ❑ Address Tele. No . <br /> r, Escrow No . --- <br /> Seller _ ______ _ Seller Address —_ <br /> Telephone No . Seller Agent Name <br /> Service Request For Date <br /> � 1 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> t V ordinances , state laws . <br /> APPLICANT' S SIGNATURE X Title Date <br /> / j <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 I <br /> BILLING REMITTANCE $BASE — EXPLANATION — — — AMOUNT DUE CHECKED— <br /> /� r <br /> DATE DATE REMITTED AMOUNT <br /> FEE O(/ O� cl ( � ;etlq <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - -- _- -_ --. — - -- _ — __ <br /> cei .d by Date Receipt No . Permit No Issw nce Date Mailed Delivered <br /> APPLICANT — RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E . HAZELTON AVE . , P.O. lox 2009 STOCKTON , CA 95201 <br />