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Y Applications Will Be PrWhen Submitted Properly Completed. Be S ^ign The Application. <br /> *A APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR rHE INVOLVED,GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLINGBROKER AND/OR REAL ESTATE INSPECTIONS Lic.IrENSE AND/OR POULTRY RANCHES AND KENNELS Re <br /> 3TRATION MISCELLANEOUS SERVICES g <br /> I. .aER ____._ Color <br /> [Application Date Business/Name To Appear On Permit _ <br /> I ype Permit/Service Requested- <br /> I.- <br /> u Applicant Name <br /> --City—of mp I a ndftq ress 146S—U <br /> u Business Telephone No. Emergency Telephone No. <br /> iProperty Location/Address Manthey Rd. , Stockton <br /> `Property Owner _ Address — <br /> Operator'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. 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 /> .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. W CONSULTATION FEE Solid Waste- 5 Year Permit <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 /> APPLICANT'S SIGNATURE X Title Date <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT_ <br /> FEE $525.0 --See Attached- 10/10189 $525.00 <br /> LESS <br /> PRORATION <br /> PLUSUNTS 30 <br /> P17NIAL_ IES WILL BE <br /> PENALTY <br /> OTHER DAYJ <br /> OTHER <br /> Received by Date Receipt No Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1.601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />