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Applications III01EIRRONMENTAL <br /> Processed When Submitted Properly Completed..; Sign The Application. <br /> APPLICATION <br /> H ALTH PERMIT/VMS <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLt WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> Ir'ENSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TRATiON MISCELLANEOUS SERVICES g <br /> I. BER --- Color <br /> R <br /> (Application Date _9 0Business/Name Ta Appear On Permit <br /> ~Type Permit/Ser 'ce Requested: — <br /> <A Iican4 N eh A dress r'rOe <br /> J t'r to Sao 2 usiness Tr4ephone7NkqEmergency Telephone N . <br /> a Property Location/Address <br /> aProperty Owner 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 13 MEAT MARKET <br /> FOOD PROCESSING PLANT ❑COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND 13 LIQUOR STORE: ® BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER 0 FOOD DEMONSTRATION 13 FOOD VENDOR f <br /> 11 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 ' ' ❑ CERTIF ANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces I <br /> 3. WATER QUALITY ® WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY 0 WATER HAULEPAPR 3 Q 199 <br /> NO. OF PUBLIC SERVED (Connections) <br /> _-4. RECREATIONAL HEALTH 0 SWIMMING POOL ❑ SPA ❑ WADING POO�NabgMNT)ktTMEATRACE <br /> 5. VECTOR CONTROL POULTRY FARM/Maximum No. of Birds PERMITSERVICES <br /> :ENNEL/Runways /Animal Population No. No. of onfinin Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source"_ Animal Waste DisposalMethod <br /> 6. ❑ CONSULTATION FEE <br /> 7. WIPLAN CHECKING F t rte_ <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. Seiler Agent Name <br /> Service Request For Date <br /> I hereby certify that 1 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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE 'DATE REMITTED AMOUNT_ <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER' <br /> Received 6y 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 9520 <br />