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Applications Will Be PrIVed When Submitted Properly Completed. Be St, To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S ANDIOR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.MOUSING _ "' Make — <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING - <br /> BROKER AND,OR REAL ESTATE INSPECTIONS Lic. No. _ <br /> ir'ENSE AND'OR POULTRY RANCHES AND KENNELS - Ret.No <br /> � 1 <br /> 3TRATION MISCELLANEOUS SERVICES g L 3 <br /> I. r3ER - - <br /> Application Date -6_49 Business/Name To Appear On Permit ENVIRONMENTAL HEALT` <br /> ES <br /> a Type Permit/Service Requested: <br /> 1,�— _ _— � C v <br /> UAp I-ica`ntr�Nlame _-Ec_�-lL'-�� ____— Address 12.4 UE 4�7� 3� <br /> _�U ISI emp — �` p Business Telephone No. o' Emergency Telephone No. <br /> -,Property Location/Address <br /> aProperty Owner _ __ _ __ Address _ <br /> Operator's Name —___. Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> 0 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 /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> r :ENNEL/Runways /Animal Population No. No. of Confining Cages i- <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Disposal Method , <br /> 6. 9 CONSULTATION FEEy <br /> 7. PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection 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, 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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT— <br /> FEE <br /> MOUNT_FEE 11/13/89 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTYr I�nl D C COUNTS X. <br /> -- - - - -r- <br /> OTHER AYS FROM 81LUCG GHTc. <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.Sox 2009 STOCKTON,CA 9520 <br />