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4: <br /> VA <br /> Applications Will Be +tossed When Submitted Properly Completed.Be S_re To Sign The Application. <br /> APPLICATION '- <br /> ENVIRONMENTAL HEALTH PERMIT/SERViGES <br /> IF VEHICLE INVOLVED,GIVE <br /> ENGrr4ER S A•,D OR FOOD ESTAEEISKMENTS.HOUSING <br /> ,cvF:.rC�Nl S AND OR Make <br /> ----__� <br /> CONTRACTOR AND Da PUBLIC PATES,WATER SAMPLING <br /> r`"YK.ER ANO OR REAL ESTATE INSPECTIONS LiC.No.�---- <br /> r:SE AND OR POULTRY RANCHES AND KENNELS Regl5t No. <br /> ;RATICIJ MISC[LLANEOUS-SERYlCES- Color ___.._.-_--------------- <br /> I. OER <br /> Application Date Business%Name To Appear Qn Permi: <br /> �i 7111 <br /> YTYpe Permlt:'Servlce Requested: ---_—_ Y r __._ ------- . n <br /> y Applicant Name- -- -- QTY r f_ ^- —,_ Address Ste=z� _ ;_•-_ ",'! -`"2L ^ni-1— i <br /> .._r!r <br /> _ Business Telephone No - _ Emergency Telephone No Properly Location;Address <br /> ., Address <br /> a?roperly Owner. -: :,C 2^ -cn_.,rnr, _ dd -'!, c .. '-r c� <br /> Cir-.c+•- Address -_ �� ^"`�' .., �. �n - _ -,_-- <br /> -tOperator's Nam. . . r <br /> 1. FOOD ESTABLISHMENTS Total Building Sq.Footage Restaurant,Maximum Seating Capacity <br /> 11RESTAURANT ❑ FOOD MARKET RETAIL EJFOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> 2 FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> Cl CONFECTIONERY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/No.of ❑ MOBILE-FOOD PREP,tJNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No.of Field Employees <br /> � <br /> ..,ALL APPLICANTS: Total Employees Including :rne Operators _ <br /> 2. HOUSING - <br /> ❑ HOTEL/MOTEL/No,of Units .CF7RTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces <br /> 3. WATER OLIALITY ❑ 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 /> 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 /> Animal Waste Disposal Method <br /> Water Supply,-Source <br /> G. n CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE r' <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspectik9-Sample Title Company — <br /> Sewage System Inspection ❑ Address Tele.No. p.¢ <br /> Escrow No. t <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 reg�ulatiions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE XA """ Titla Date <br /> TIE _ '" FOR DEPARTMENT USE ONLY <br /> I Fee_IS_a711e:❑ANktIfALLY ❑PER UNIT ❑ PER SITE ElEACH ❑ January 1 8 Recei ed By January 31 ❑July 1 8 ReceIv REMITd By uly 31 <br /> f <br /> EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED. <br /> DATE DATE REMITTED AMOUNT <br /> r <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY _ <br /> . L)THER l j <br /> OTHER - ✓� ! I-� �` .-r�� <br /> ` Ppf nl,l N0. ISSuance Dale Mailed - Dellvered - <br /> erved OY Dale rie[e'pt NO <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERAIITISERVICES 7601 E.HAIELTON AYE„P.O.Bas 200Y STOCKTON'CA ti3205 <br /> Im . <br /> CANWT <br /> BE <br /> IMPROVM To <br /> ODWITION or. TWCKGM& <br />