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Applications Will Be Prr sed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> "FRI APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVIrts <br /> ENGWEERS 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 /> CENSE AND OR POULTRY RANCHES AND KENNELS <br /> ;TRATION MISCELLANEOUS SERVICES Regist. No. _.. .. <br /> i. BER �i Color <br /> Application Date ��-__ f1�J�/ Business/Name yo App ar n Permit /%����Z <br /> HType Permit/Servic e s ,ILLI- � - -�� ^^�'C� `% <br /> <A cant Name r __ - - _. t�Address �Q- ��e5� <br /> -�- �j <br /> U <br /> siness Telep �n�e No. {l - �-�z Emergency Telephone No. <br /> a Property Location/Address �� ��a f �L ---- ---- -- <br /> aProperty Owner 1� �� � - — Address -- -- - - - — <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 /> ❑ 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 <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method _— <br /> Water Supply Source ___ f imal Wast Isposal Method <br /> � <br /> 6. E , ONSULTATION FEE -/Ci� - `�� - <br /> 7. ❑ PLAN CHECKING FEE —- <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 r <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 6 Received By July 31 <br /> T _._—___ - -�-- REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> + ��/,yf --- - -- - - -- - - --- - - - -- -- -- -- <br /> FEE + 7� t <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ved by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> PPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 r <br />