Laserfiche WebLink
Applications Will Be# APPLICATION <br /> ssed When Submitted properly Completed. Be a To Sign The Application. <br /> .:_ <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINF_E,#1,'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPDGANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make <br /> COrTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING - --- - <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. __- <br /> i(-ENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> I. .AER ... q Color <br /> pplication Date _ YRquested: <br /> Business/Name To Appear On Permitv)TypePermit/Servic __F <br /> .zApplicantName mS �� U1. - __ ____ Address I - `J i <br /> Business Telephone No— -� rA�Z' <br /> mergency Telephone NoProperty Location/Address G p�f,2�"fZ -_ -_ _ TSI ___ ._ s___ <br /> J Property Owner-17 !I, ---__- _ - ----_-_ Address ---_--_ -- --_ <br /> Operator's Name __� __kl _ _l61 Address -------- Cl C WWL _ <br /> 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 11 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 /> • <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units -. _ ❑ CERTIFICATE OF OCCUPANCY <br /> P MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY 0 WATER SAMPLE (Bacterial) ❑ CHEMICAL F <br /> ❑ PUBLIC WATER SYSTEM 0 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 <br /> 7. ❑ PLAN CHECKING FEE — <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection 0 Sample Title Company <br /> Sewage System Inspection ❑ Address _- __ <br /> -- -------- --Tele. No. <br /> Escrow No. <br /> Seller------_._ -.-_-- -.- ___------ Seller Address <br /> Telephone No ___-____ _ Seller Agent Name -_ ------- <br /> Service <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. <br /> APPLICANT'S SIGNATURE X __ _ _____ _ Title _T 'zlwC Date ?A 2 94 <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 /> — --------- —T REMIT <br /> BASE EXPLANATION <br /> BILLING REMITTANCE ( $ <br /> ( AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> --- -- I ----- AMOUNT <br /> Q <br /> FEE -- 66 <br /> - <br /> ---' <br /> LESS <br /> PRORATION . - <br /> PLUS \ �k <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Rec ed by Date Wipt No. Permit No. Issu#Jate Mailed Delivered <br /> 1. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERNIMSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201— <br />