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k+ r <br /> Applications Will Be Procr--%ed When Submitted Properly Completed. Be Surf Yo Sign The Application. 1 <br /> s7APPLICATION , i <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> � r IF VEHICLE INVOLVED, GIVE <br /> ENGiNEER'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make I <br /> APPLICANT'S AND/OR PUBLIC POOLS.WATER SAMPLING <br /> CONTRACTOR AND/On REAL ESTATE INSPECTIONS Lic, No. <br /> BROKER ANO/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> .ICENSE AND/OR MISCELLANEOUS SERVICES <br /> -�TRATION Color <br /> I. BER <br /> Application Date Business/Name To Appear On Pe- ii, <br /> yType Permit/ eryice ,e es a '� fK `~ <br /> �.lr� <br /> Address <br /> a Applicant Name <br /> � � `'� Business Telephone No� Emergency Telephone No. <br /> CL <br /> Property LocationlAddress <br /> Property Owner �� � i <br /> K Address <br /> -tbperator's Name <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET es. <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 ❑ CERTIFICATES& OCCUPANCY <br /> II ❑ 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 1:1SWIMMING POOL ❑ SPA E3WADING POOL C1NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> Ir .ENNEL/Runways /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method k <br /> Water Supply Source Animal Waste Disposal Method <br /> 6. )Z,CONSULTATION FEE Aps o6 3 - <br /> 7. ❑ PLAN CHECKING FEE <br /> B. 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, and rules and regulations of the San Joaquin Local Health District. <br /> fn i (� ��1�Y11 QC <br /> APPLICANT'S SIGNATURE X Title�_.�-_- �1i Date <br /> joplu— <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED' <br /> DATE DATE REMITTED AMOUNT <br /> n <br /> FEE <br /> LESS tl <br /> I <br /> PRORATION <br /> PLUS 1 '{y. <br /> PENALTY <br /> OTHER �� r <br /> OTHER S� —^'---- � <br /> 4 <br /> Re eyed Date _ Receipt No. Permit No. Issuance Date Mailed Delivered <br /> !f by <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />