Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S ANDrOR 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 Lic. No <br /> Ir'•ENSE AND/OR POULTRY RANCHES AND KENNELS <br /> STRATION MISCELLANEOUS SERVICES R¢gl5t. No <br /> I. AER II q Color <br /> Application Date (li,$ Business/Name To Appear On Permit <br /> mType <br /> i Permit/Servi1oeRe/^gue.�,stte_d <br /> Applicant Name l)kA" /n. ------_ ----__-.-..-_._ Address QI3n-oe <br /> Lao -- -- <br /> ZAP Business Telephone No - --_ _._._ __ Emergency Telephone No -. - - - <br /> iProperty Location/A dress -�52 C- (7-TF2- w - <br /> ,Property Owner <br /> Address <br /> Add _ -- <br /> a <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 DUALITY ❑ 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 /> F :ENNEL/Runways __. __- -_ _ _ /Animal Population No. _ _ _—__ No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source _ � Apimal Yjaste Disposal Method - <br /> 6. r CONSULTATION FEE SIAA-1�"SLdI.� lu—" <br /> 7. PLAN CHECKING FEE - <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 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 6 RecefwKI By January 31 ❑ July 1 A Received By July 31 <br /> BILLING REMITTANCE { <br /> REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> _ I AMOUNT_ <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY T ��vv <br /> OTHER O.I. . t�.2' . <br /> OTHER t} v 4 .bD <br /> .LAN-w�-r� --_-_ I V <br /> Recmv b by Date ReeelPt No. Permll No Issuance Dale Mailed Delivered <br /> .nm 11.u�-acmeu u. rneren♦n ewrenuueuru ueu vu eceuwvl.comrce .cmc uucl mu.ve en e...vuw ernremu r.asvm <br />