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Applications Nfil Be P '-%sed When Submitted Property Completed.<Be S,._.,To Sign The Application. <br /> APPLICATION SR k <br /> ENVIRONMENTAL HEALTH PERMITf R 1 <br /> paap ESTABLISHMENTS,HaUSING iF VEHICLE INVOLVED,GiVE <br /> ENGINEER'S AND/OR Make <br /> APPLICANT'S AND/OR PUBLIC POOLS.WATER SAMPLING _ <br /> CONTRACTOR AND/Oh REAL ESTATE INSPECTiONS t � Lic, No. - - <br /> BROKER ANOIOR POULTRY RANCHES AND KENNELS J >tqkvl',�No: <br /> it ENSE AND/OR MISCELLANEOUS SERVICES <br /> 3TRATION ,},t'Ls.7 .ttcsl9r — <br /> �J <br /> Application Date -_ _ Business/Name To Appear On Permit _ - - - -- <br /> __��^_ <br /> ,Type Permit/se vice Requested-, — Address <br /> — — -- ' <br /> Z - <br /> plicant Nam _ Emergency Telephone No, <br /> v ? Business Telephone No ._._- g <br /> IL o ert Location/ ddres <br /> -ca Address <br /> -Property Owner C <br /> . Address <br /> -LOperator's Name - Restaurant,Maximum Seating Capacity <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage ❑ MEAT MARKET <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY C1 ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ ROADSIDE F ODARY 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 /> 8. WATER QUALITY ❑ WATER SAMPLE(Bacterial) ❑ CHEMICAL <br /> C3 PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY 13 WATER HAULER <br /> NO.OF PUBLIC SERVED (Connections) __,_ - <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA 11 WADING POOL ❑ ,NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.9f Birds . <br /> ENNEL/Runways __ /Animal Population No. -- No.of Confining Gages w <br /> Sewage Disposal Method <br /> Solid Waste Dsposai Method .- _- - . ..- - <br /> Water Supply Source - - - Animal Waste Disposal Method <br /> g, CONSULTATION FEE L't <br /> 7. PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well inspection Sample❑ Title Company _ -- <br /> Sewage System inspection ❑ Address LL _ Tele. No, <br /> Escrow No. - <br /> Seller Seller Address �- <br /> Telephone No. Seiler AgentName _ — <br /> Service Request For Date -- -- - _ <br /> I hereby certify that I have prepared this application and that the work will be dune 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 Otte= ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t&Received By January 31 ❑ July 1 &-Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE: DATE: .REMITTED AIti1©ttNT <br /> FEE � t t --j2L12 -- S35.00 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY`- <br /> ..-----. <br /> OTHER <br /> OTHER / --'e <br /> f l '65 — <br /> R ved by Date Receipt No, Permit No is Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES T9: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..13.0.Bax 2009 'STOCKTON,CA OS201 <br />