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Applications Will Be d When Submitted Properly Completed. Be 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 /> IrFNSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TRATION MISCELLANEOUS SERVICES <br /> i. .BER Color - -- ------ -- <br /> Application Date _�o-L�-R)b Business/Name To Appear On Permit <br /> Type Permit/Servi eques ed: - <br /> a Address _ _ _. - G <br /> f <br /> �� - 6 "[ f'12� __ �} Business Telgphone No. - _ Emergency Telephone No. <br /> It Property Location/Address W20 -�4iV11C r--� u -- - <br /> --- <br /> fyProperty Owner-_ - Address _- <br /> a - <br /> Operator's Name _ - -- -- - -- - Address - ------- -- - -- <br /> 1.r 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 s� Animal Wast Disposal t EdNT <br /> 6. CONSULTATION FEE - <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE 1 �o <br /> REQUEST: Water Well Inspection❑ Sample[] Title Company _ _ -_ _ - NOV��-+�OC7 <br /> Sewage System Inspection ❑ Address -__ __-_ _ -_ _- Tele. No. <br /> Escrow No. - ENVIRONMENTAL HEALTH <br /> Seller - Seller Address -- ------ -PER.tATIc S -- -- <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 SIGNATURTitle. Date <br /> n <br /> ,"FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &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 J :'i'1J: Li JE A <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY nn pn <br /> OTHER L�./$$_ . <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.Box 2009 STOCKTON.CA 95201 <br />