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Applications Will Be Pr d When Submitted Properly Completed. Be S Sign The Application. <br /> ! APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVIC <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS P,q ► <br /> .Ir'ENSE AND/OR POULTRY RANCHES AND KENNELSR c' T <br /> 3TRATION MISCELLANEOUS SERVICES y1 D <br /> I. BER — Color <br /> `' <br /> AUG 193 <br /> rApplication Date Business/Name To Appear On Permit J <br /> ,nType Permit/Service Requested: , <br /> Applicant Name Address Tq <br /> 95209 <br /> — Business Telephone No. Emergency I�c{ So. <br /> CL <br /> Property Location/Address_ 245 Weber, Stockton <br /> aProperty 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 /> 5. 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. IBJ CONSULTATION FEE Solid Waste Permit <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. 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 an re ulations of the San Joaquin Local Health District.. <br /> APPLICANT'S SIGNATURE Title �° �= T Date U 6 0 � <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT_ <br /> FEE 507 .50 See <br /> LESS <br /> PRORATION <br /> PLUS DE <br /> PENALTY <br /> OTHER DAYS FRCM BILLING DATE. TS 30 <br /> OTHER <br /> S -7, o <br /> Receive y cfate Receipt No. Permit No. Is.sliance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1.601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br /> PUBLIC HFAI TH SFRVTr..FS <br />