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Applications Will Be r'`^.eased When Submitted Properly Completed. Be -e To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <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 /> .irENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> 1. a3ER Color <br /> (Application Date 1��Rf3 - Business/Name To Appear On Permit <br /> ~Type Permit/Service Requested: <br /> a Applicant Name;?FJTiG �'hWoP-r„1 ur.,)-r?tt Address _� <br /> �t� � 1 7 �• lii C e.✓ <br /> 1 i pNn,h4 .CA. q 5 0 Business Telephone No.A � Emergency Telepfione N'o'.' � <br /> s Property Location/Address.WX l 0644' r-44 i4,�ft,�e _S-r'. — <br /> Mj Property OwnerAdWi <br /> a � <br /> - Operator'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 /> ❑❑ CERTIFICATE OF OCCUPANCY HOTEL/MOTEL/No. of Units � <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 /> F .ENNEL/Runways /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water,Su ply Source Animal Waste Disposal Method � �a�.. <br /> 6. 4 CONSULTATION FEE ' <br /> 7. ❑ PLAN CHECKING FEE <br /> `i <br /> a. REAL ESTATE F` <br /> REQUEST: Water Well Inspection 13 Sample Title Company � `'- FO- <br /> Sewage '- <br /> Sewage System Inspection ❑ Address Tele No., <br /> Escrow No. �cP <br /> Seller Seller Address v <br /> Telephone NoP Seller Agent Name <br /> Service Request For Date <br /> 1 <br /> I hereby certify that I have prepared this application and that the work will he 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 8 Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE C0 <br /> I <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <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.,Q.O.Bo■2009 STOCKTON,CA 95201 <br />