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ENGINEER'S AND•OR <br />APPLICANT'S AND/OR <br />CONTRACTOR ANO/OR <br />BROKER AND/OR <br />irFNSE ANDIOR <br />STRATION <br />a. .aER <br />Applications Will Be Prc ed When Submitted Properly Completed. Be Su 3 Sign The Application. <br />APPLICATION .-/ <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />FOOD ESTABLISHMENTS. MOUSING <br />PUBLIC POOLS. WATER SAMPLING <br />REAL ESTATE INSPECTIONS <br />POULTRY RANCHES AND KENNELS <br />MISCELLANEOUS SERVICES <br />IF VEHICLE INVOLVED, GIVE <br />Make — <br />Lic. No. <br />Regist. No. <br />Color <br />Application Date _U2 -l? 0.�B•-usi_ne�ss/�ame To AppearOnPermit <br />FType Permit/Service + Fllegque�sted �TLVY_�1_�r��C,2 ,(lam �C� f pr, """ r — <br /><Aon pyli'can Nam'e^—,S ZS:X f �.[,_5_/_u Address �a� e(JyL- S "' <br />f--rx�-9 _s a /3 / Businessa Telephone No. Emergency Telephone No. <br />i Property Location/Address sP <br />r�a-S , - (O ^��' n j <br />Property Owner �]Jq.�J _. =7 Address 3-C��--/(/• __�'(-G y <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 />❑ ROAOSIDE 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/ND. 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 />Snlirl Waste Disnnsal MPthnrt <br />WaterrSS poly Source Animal Waste Disposal Method e <br />6. L7 CONSULTATION FEE —� feI l (4/j� ` ,r c / ' °--C:';I (�/_,� <br />n <br />S. 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 <br />Title <br />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 />REMIT <br />BASE <br />EXPLANATION BILLING <br />REMITTANCE $ <br />AMOUNT DUE <br />CHECKED <br />DATE <br />DATE REMITTED <br />AMOUNT <br />FEE <br />S <br />' rQ <br />LESS <br />14-0 <br />/ <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />�_l'�,/ILLBEAPPLIE-DT <br />PASIDI Ir: <br />Received by Date Receipt No Permit No Issuance Dale Mailed Delivered <br />—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 16111 E. HAZEL <br />