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IRONMENTAL HEALTH PERMIT/SERV, S <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 /> IrFNSE AND/OR POULTRY RANCHES AND KENNELS Re ist. NO. <br /> aTION MISCELLANEOUS SERIf1CFS g - <br /> -- -—- Color - <br /> Application Date__6_i -z -E-��3 Business/game To Appear On Permit <br /> o Type Pe(mit/Service Fidquested: <br /> APp}cant Neme _ -_- -�' - <br /> eSS <br /> ss Telephoncv TJE� o. <br /> e No. �O �. <br /> Property Location/Address - <br /> - - -- -- <br /> dProperty 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 ❑ 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 C 1/ <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL - I <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 /> r NNEL/Runways /Animal Population No No.of Confining Cages <br /> Sewage Disposal Method -- <br /> Solid Waste Disposal Method <br /> W t�er Supply Source Animatl•MOisposal M od <br /> 6 j�'�"CONSULTATIOWFEE �� N� xm%C,- <br /> 7. ❑ PLAN CHECKING FEE _ <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection[] Sample 11 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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE r LetsL5 <br /> LESS <br /> PRORATION i <br /> PLUS ---- - <br /> PENALTY - I <br /> OTHER <br /> v Jv f <br /> OTHER --- - ; <br /> Ne, Wby Datb 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 2000 STOCKTON.CA 95201 <br />