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Applications Will F •ocessed When Submitted Properly Completed. " Cure To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF V IN LVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS <br /> .Ir'F_NSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES g No. <br /> I, .aER --_. Color <br /> f Application Date "o Busiryess/N a T-- r On Per it �� <br /> IH Type Permit/Service equested: — _ <br /> i Applic t Name Address <br /> a � 11�usjpess Telephone 0;4—�ZEmergency Telephone No. <br /> Property Location/Address.— _��F• 3- _ _ L <br /> `ProNerty Owner!—CJidress <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 /> .ENNEL/Runways /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source __ F —3nimal Waste Disposaj.Method <br /> 6. CONSULTATION FEE '� <br /> T. ❑ 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 <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 /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> /�,����(y AMOUNT_ <br /> FEE ,� 6^�i•r"v�7 6123/89 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER PER <br /> OTHER DAYS FR MBI LING <br /> Ll 3 7, sa el Cl s Z <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.Bolt 2009 STOCKTON,CA 95201 <br />