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Applications Will Be Pr ed When Submitted Properly Completed.Be S o Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> bENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S ANO/OR FOOD ESTABLISHMENTS,HOUSING <br /> ONTRACTOR ANO/OR PUBLIC POOLS.WATER SAMPLINGMEWMake <br /> KER AND/OR REAL ESTATE INSPECTIONS Lic. No.IW.r:NSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TRATION MISCELLANEOUS SERVICES <br /> i. .8ER ----------_.---------... Color <br /> Application Date_J I-��31�o Business/Name To Appear On Permit <br /> ,ATYpe Permit/Service Requested:__-. <br /> i ---------_ Ad-d-res-s-_-'-��--0�-'-1-f-n-'N_Q.-/S-7-Y--5-72------S--EM---i�"7-, <br /> �-rppcan -� T _- -- <br /> J.0,C) �L.?�=s3 f Business Telephone No. _ Emergency Telephone No. <br /> `Property location/Address_ -�_� i1NL _� ,s� � <br /> aProperty Owner -_- __ Address.__ <br /> -LOperator'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 /> VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> :ENNEL/Runways - /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method -- <br /> Solid Waste Disposal Method <br /> Water Supply Source _ Animal Wast TDisposal Method <br /> 6. rdi CONSULTATION FEE W 11 95-5- D mol L_ Seryl-IPf'&]C--r- o_ 1j8 9oiq/'q' I- <br /> B. 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 <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 A Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE 35 Mr- SOIL �" Do <br /> X$ 150M PLL aX <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date eceipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />