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plicelions WIII ocessed When Submitted Properly Completed. ure To Sign The Application. <br /> ' APPLICATION 0 <br /> ENGINEERS AND/OR <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR V1, �� PUBLIC POOLS, WATER SAMPLING Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. NO. <br /> .IeENSE AND/OR POULTRY RANCHES AND KENNELS <br /> STRATION MISCELLANEOUS SERVICES Regist. No. <br /> I, .dER __. Color <br /> �/,Ar//r I �. <br /> [Application Date u ss/Name T Appear On Permit _./ ` wle L/ _ ��._G� o�r� <br /> ~Type Permit/Service quested:—_� <br /> `�"-'-"`t- --- -------- �r- <br /> Applicant Nam 'C AddressLCL <br /> u Business TelepJ,ione No..C2%-�S Y�p,,,— gency Telephone No. <br /> i Property Location Address n ntm v � o{- 42 ' <br /> Property Owner ~�— <br /> 1i Address <br /> 0perator's Name Address <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. <br /> perators _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 /> S. 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 /> Watery S pply Source Animal Waste 'sposal Method <br /> 6. K CONSULTATION FEE <br /> 7. ❑ .PLAN.OHECKING FEE <br /> 6. REAL ESTATE <br /> REQUEST: Water Well Inspection Sample[] Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <br /> Escrow No. <br /> Seiler 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 Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EA GH ❑ January 1 8 Received By January 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE $ <br /> REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTE'�Dll��II AMOUNT <br /> \ FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY PENALTIESWILBEAPPLIE <br /> OTHER AYS FROM ILLING DAT <br /> E OTHER <br /> ►Z�s�� rte- � tis � � �c _ <br /> Received by Date Recelpl No Permit No Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95101 <br />