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Applications Will BejFsd"When Submitted Properly Completed. Bie To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOR AND/OR t PUBLIC POOLS,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 /> [Application Datex lqco usiness/Name To Appear On Permit IT <br /> `(i OPbo,(A IA <br /> wType Permit/Service Re'. ed: -- <br /> a Applicant Name x r Addr ss <br /> ae' t Business el ne No%ell IM . 'Q O Q Emer cy Telephone No. <br /> a Property Location/A ess K <br /> aProperty Owner7C Address ,UA 2 s <br /> Operator's Name Address C �l <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 W to Disposal Method <br /> 6. 'CONSULTATION FEE .�i2Sl,GPE 'T/�PLfJCC l`���C1Sl�G U2 ja _. <br /> 7. ❑ PLAN CHECKING FEE <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. 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 accor ith San Joaquin County <br /> ordinances, state laws, an ules and reg tions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATUR X Titley n u Date x- U <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received BI <br /> January 31 ❑ Julybl &Received By July 31 <br /> B ° REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT Dt It CHECKED <br /> DATE DATE REMITTED ., <br /> AMOUNT <br /> FEE �` <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Amok <br /> 3�9 0 <br /> Received by to pt No. Permit No. Issu ate Mailed Delivered <br /> 1 APPLICANT—RETURN ALL COPIES TO: ENVI ENTAL HEALTH PERMIT/SERVICES 1601 E.HA2 N AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />