Laserfiche WebLink
Applications Will Be Pro �-!d When Submitted Properly Completed. Be Surv-"o Sign The Application. <br /> 1-�,' APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEE.R'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 /> -FNSE AND.OR POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TRATION MISCELLANEOUS SERVICES -- - _--- ---- <br /> "I— .dER Color - -- <br /> Application Date Q "1- -k-' Business/Name To Appear On Permit <br /> in Type Permit/ServicequesteG - - - - <br /> `Applicant Name Address <br /> A�Usine:�Teel hone No. - __. __ Emergency Telephone No. _ <br /> OR Property Location/Address - -- -- - - -- - -- -- <br /> <Property Owner _._. j-. 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 11 WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM 11 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 /> \_1 :ENNEL/Runways /Animal Population No. - .._ _ .. ._ . No. of Confining Cages <br /> Sewage Disposal Method _ <br /> Solid Waste Disposal Method <br /> Water Supply Source tt _ Animal Waste Disposal Method <br /> 6. 0 CONSULTATION FEE <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 Nc Seller Agent Name <br /> Service Request For Date <br /> I hereby certify that 1 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 $ <br /> REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUSPENALTY <br /> OTHER + h <br /> OTHER v <br /> Rec d by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> A LICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />