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Applications Will Be Pr messed Wher, Submitted Properly Completed. Be To Sign The Application. <br />_ APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />ENGINEER'SAND/OR IF VEHICLE INVOLVED, GIVE <br />APPLICANT'S AND/OR FOOD ESTABLISHMENTS. HOUSING Make <br />CONTRACTOR AND/OR PUBLIC POOLS. WATER SAMPLING <br />BROKER ANO/OR REAL ESTATE INSPECTIONS LIC. No. <br />IrENSE AND/OR POULTRY RANCHES AND KENNELS <br />3TRATION Unit Iii MISCELLANEOUS SERVICES Reg !St. No. . .. _ <br />I. .AEP _.__. _-__-_ _- Color_ --- —._. — <br />Application Date __._ ._—___ —__ Business/Name To Appear On Permit <br />mt Type Permit/Service Requested: <br />S <br />Applgant ame � $ ice}--_— -_.— Address _ <br />d —.7_. >' _ .Business Telephone <br />-Property Location/Address _ 1+2 S. Ceht2S� $tQCkton <br />iProperty Owner Address —._. <br />Operator's Name --_ __ Address <br />P, Q__jkX_50a_- - - <br />Emergency Telephone No. <br />1. FOOD ESTABLISHMENTS <br />Total fIuilding Sq. <br />Footage Restaurant, Maximum Seating Capacity <br />❑ RESTAURANT ❑ FOOD MARKET RETA ❑ FOOD MARKET WHOLESALE <br />❑ MEAT MARKET <br />❑ FOOD PROCESSING PLANT <br />❑ COMMISSARY <br />❑ ICE PLANT <br />❑ BAKERY <br />❑ ROADSIDE FOOD STAND <br />❑ LIQUOR STORE <br />❑ BAR <br />❑ ITINERANT RESTAURANT <br />❑ CONFECTIONARY STORE <br />❑ FOOD SALVA&ER <br />❑ FOOD DEMONSTRATION <br />❑ FOOD VENDOR <br />❑ VENDING MACHINES/No. of <br />❑ MOBILE FOOD PREP. UNIT <br />❑ VENDING VEHICLE <br />❑ FOOD CROP HARVESTING/No. of Field Employees ALL APPLICANTS: Total Employees Including OperatorsT <br />2. HOUSING <br />❑ HOTEL/MOTEL/No. of Units <br />❑ MOBILE HOME PARK/No. of Spaces <br />3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) 6\CHEMI <br />❑ CERTIFICATE OF OCCUPANCY <br />❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY \❑ WATER HAULER <br />NO. OF PUBLIC SERVED (Connections) N <br />d. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WING <br />5. VECTOR CONTROL 13POULTRY FARM/Maximum No. of Birds <br />i 'ENNEVRunways /Animal Population No. <br />Sewage Disposal Method <br />Solid Waste Disposal Method <br />Water Supply Source _. Animal <br />6. ❑ CONSULTATION FEE Additianal field in=Artirn titr <br />7. ❑ PLAN CHECKING FEE <br />6. REAL ESTATE <br />REQUEST: Water Well Inspection 13 Sample❑ Title Company — <br />Sewage System Inspection ❑ Address <br />Escrow No. <br />Seller Seller Address — <br />Telephone No. _ Seller Agent Name <br />Service Request For Date —_ <br />POOL ❑ NATURAL BATHING PLACE <br />No. of Confining Cages <br />Was Disposal Method <br />Tele. No. -- - <br />I hereby certify that I have prepared this application and that the work will be done in accordance vitkh San Joaquin County <br />ordinances, state laws. <br />APPLICANT'S SIGNATURE X <br />Title <br />FOR DEPARTMENT USE ONLY <br />Fee la DUO: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i A Recehed By January 31 ❑ July 1 A Received By July 31 <br />BASE <br />EXPLANATION <br />BILLING <br />,,,Y. � <br />II�` <br />REMITTANCE <br />DATE <br />S <br />REMITTED <br />AMOUNT DUE <br />REMIT <br />CHECKED <br />AMOUN <br />FEE <br />$140.00 <br />Field Insp <br />action <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />$14.00-. <br />Peml <br />12-21-90 <br />$154.00 <br />OTHER <br />_ <br />OTHER <br />Received by Date Receipt No Permit No Issuance Dale Mailed Delivered <br />