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Applications Will Be Pr,"3sed When Submitted Properly Completed. Be$,­-To Sign The Application. <br /> *y+ APPLICATION *4w <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGfNEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANTS AND/OR FOOD ESTABLISHMENTS,HOUSING Make .__.. - <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> ;rENSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> - <br /> STRATION MISCELLANEOUS SERVICES g ------ -- <br /> I. ZER - �[ oa Color <br /> Application Date —"TJ� _. .. . Business/Name To Appear On Permit <br /> FType Permit/Service Requested: <br /> a Applicant Name Address <br /> _ Business Telephone No. -- Emergency Telephone No. <br /> a U <br /> 'a Property Location/Address Pr—Uhf' <br /> aProperty Owner S f°uF21 L�ll� _ _ _ _ _ _ Address <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 /> r :ENNEL/Runways /Animal Population No. _ No. of Confining Cages <br /> Sewage Disposal Method -- ----- <br /> Solid Waste Disposal Method -- <br /> Water Supply Source _ — Animal Wt Dispgsa Mk[Lethod _ <br /> 6. CONSULTATION FEE j1 ST1 �' �-- <br /> 7. 11 NA4rx- <br /> ❑ PLAN CHECKING FEE - — — - -- <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection Sample 13 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.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 /> ` BILLING__7 REMITTANCE $ REMIT <br /> BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTYAD <br /> ., Jr� /� -- - .�}-72J—_ ----_-- . <br /> OTHER iC/�,/(J fl ./lJ� IrIQ}� <br /> OTHER ` <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />