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Applications Will Be Prov.ed When Submitted Properly Completed, Be Sure To Sign The Application. <br /> ` y APPLICATION <br /> ERVIRONMENTAL HEALTH PERMIT/SERV? tS <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 ANO/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. . — — <br /> I, i3ER __. Color <br /> Application Date zZ Business/Name To Appear On Permit EelV1 i 12le 17•t <br /> r)Type Permit/Service Requested:_._. <br /> UApplicant Name w ' — AddressD BDZC _ yZ MQrCi'c� 953 <br /> d--- Business(Telephone No. a y�_ Emergency Telephone No.(z�f} <br /> CC- <br /> IL Property Location/Address_.�`� � �}, .�T� � /� @ c-c1 S (o _ <br /> ;Property Owner uf; .'� Address F�� gt�C �07 __ . ✓1 y �acl <br /> -LOperator's Name L Address SAME <br /> f. 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 /> .ENNEL/Runways _ _ /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method - <br /> Solid Waste Disposal Method - <br /> Water Supply Source Animal Waste Disposal Method <br /> 6. ;Q CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE <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 <br /> / K <br /> rulessA�a�nd regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X .—A— "� Title(." azL Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 R Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 3S <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. J� Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo=2009 STOCKTON,CA 95201 <br />