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Applications Will Be Prcp-,---)ed When Submitted Property Completed. Be Su�To Sign The Application. <br /> %A1111111. APPLICATION -0" <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> IF VEHICLE INVOLVED, GIVE <br /> ENGINEER'S AND/OR F000 ESTABLISHMENTS,HOUSING <br /> APPLICANT'S ANDiOR Mak@ - <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING - <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> OR POULTRY RANCHES AND KENNELS Regist. No.---- <br /> RENEE AND/ <br /> --- <br /> ;SEAND/ MISCELLANEOUS SERVICES - - <br /> Color ._ <br /> 1. AER <br /> Application Date - <br /> Business/Name To Appear On Permit X11✓ - S ���� "�G - - <br /> u,Type Permit/Service Requested: - <br /> xE +-_ /¢. i¢.E cc�v_ �c�.Address_ <br /> U Applicant Name <br /> C�,.. C� _. Business Telephone No. boy_ 976-=«sf_ Emergency Telephone No._ S <br /> .Property Location/Address <br /> ;Property Owner _�� � v �_ ^�c_ ...... �� _..__- Address <br /> a - - <br /> 1Operator's Name ��- — Address _...s . <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 Cl 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 /> 11HOTEL/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 Waste Disposal Method ---. <br /> 6. ❑ CONSULTATION FEE -. 1044e0,5C 49 z- ��/Com' <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE y� <br /> REQUEST: Water Well Inspection 13 Sample7�. 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 E <br /> BASE I EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No �— Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16011 E.HAZELTON AVE.,P.O.Ban 2009 STOCKTON,CA 85201 <br />