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Applications Will Be 0 <br />ssed When Submitted Properly Completed. Be 0 <br />To Sign The Application. <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />ENGINEER'S AND/OR <br />APPLICANT'S AND/OR <br />CONTRACTOR AND/OR . -- <br />BROKER AND/OR <br />IrENSE AND/OR <br />1. t3ER <br />FOOD ESTABLISHMENTS. HOUSING <br />IF VEHICLE INVOLVED, GIVE <br />PUBLIC POOLS, WATER SAMPLING <br />Make __. <br />REAL ESTATE INSPECTIONS <br />Lic. No. <br />POULTRY RANCHES AND KENNELS <br />MISCELLANEOUS SERVICES <br />Regist. No. <br />9 <br />DATE <br />Color <br />[Application Date=�z%-��'� Business/Name To Appear On Permit _ <br />a Type Permit/Service Requested:-12,�t��r�.3 <br />v Applicant Name —_��f� �7�� (�i?5 7��(/ ��� 4ddress <br />Business Telephone No. — Emergency Telephone No. <br />a Property Location/Address <br />Property OwnerQ �— /� � Ste• _�'��Gc ddress '??Actic <br />Operator's Name Address <br />T• 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 Employeesui7 `JkGC S�7,4,ZAv �c <br />ALL APPLICANTS: Total Employees Including Operators) 2. HOUSING <br />HOUSING 2Cc r rt5 <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 />.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 <br />7. ❑ PLAN CHECKING FEE <br />8. REAL ESTATE <br />REQUEST: Water Well Inspection 13 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, and rules and regulations of the San Joaquin Local Health District. <br />APPLICANT'S SIGNATURE X <br />Title <br />Date <br />FOR DEPARTMENT USE ONLY <br />Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ FAr.14 n ice., —.. , a a ...... A a.. <br />BASE <br />EXPLANATION <br />BILLING <br />REMITTANCE <br />$ <br />AMOUNT DUE <br />REMIT <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />FEE0-0 <br />LL <br />AMOUNT <br />-- <br />(( <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />Received by Date <br />APPLICANT—RETURN ALL COPIES TO: <br />No. Permit No <br />TAL HEALTH PERMIT/6ERVICEO <br />issuanOW41e Mailed Delivered <br />1.0019. HAZ9LTON AVE., P.O. Box 2009 STOCKTON, CA <br />