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Applications Will Be Pron"3ed When Submitted Properly Completed. Be Su!NTo Sign The Application. <br /> APPLICATION '4.001 <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLI FOOD ESTABLISHMENTS,HOUSING Make <br /> ONTHACTORA PUBLIC POOLS,WATER SAMPLING <br /> BR AND/OR REAL ESTATE INSPECTIONS Lic. No. -- <br /> .IrFNSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TRATION� MISCELLANEOUS SERVICES g <br /> 1. .8ER 1f�r!1'"-7 a—, -5 Color <br /> Application Date Business/Name To Appear On Permit — <br /> ,nType Permit/Service Requested:11- <br /> — <br /> a Applicant Name �) IC ic- Address_ — <br /> U <br /> Business Telephone No. Emergency Telephone No. <br /> a Property Location/Address Y C� c`Q <br /> <Properly Owner Lj'O -30 V 40 QV-< _ 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 SS �ry Source Animal Waste Disposal Method <br /> 6. L1 CONSULTATION FEE W L� v L eoY 4 x �,_�__ -z .� �5 �. �,cA 9l <br /> 7. ❑ PLAN CHECKING FEE <br /> a. 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, an ies an regulations of he San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X Title Date - 3 <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE vY � ray <br /> S t r� iPe- s <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ei ed 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.Box 2009 STOCKTON,CA 95201 <br />