Laserfiche WebLink
ENGINEER'S AND/OR <br />APPLICANT'S AND/OR <br />CONTRACTOR AND/OR <br />BROKER AND/OR <br />I rENSE AND/OR <br />STRATION <br />I BER <br />Applications Will Be P •.sed When Submitted Properly Completed. Be F , To Sign The Application. <br />-- APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />FOOD ESTABLISHMENTS. HOUSING <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 />a - - <br />---- - Color <br />Application Qate _ �7Busiiness//Naame To Appear On Permit � > �____ Q�L%�S�/✓ <br />`Type Permit/Service ate _`/ <br />u Applicant Name '�'���7 LL (1���- ��� Arddddrreess, I �� Q�«A7/R -Ey .�1�1 /O/)' / <br />_ Business Telepho� No. - V— �5 rj' Emergency Telephone No. �gz �S-� L <br />rop��erty L��ocation/Address /Q//A�%s��.i¢ r9�-0/''��.f/ . <br />iProperty�Tlil'_, _ %/ lliJ>�SG��1� -._ Address=2RZ .=�/-�/�/�l0 /�i�l.� 4ey) <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 ��/L ��/��//5������✓ <br />❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br />NO. OF PUBLIC SERVED (Connections) <br />A. 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 />cow�,.e ni�.i Anoth, d <br />e..un w�tm nl�,...�sl aaoth..d <br />Water Supply Source - Animal Waste Disposal Method <br />6. 0 CONSULTATION FEE - <br />7. ❑ . PLAN, CHECKING FEE <br />8. MEAL ESTATE <br />REQUESTS 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 rulepond re ul to f t�he`/fin Joaquin Local Health District. fi <br />APPLICANT'S SIGNATURE X�[��• >S�l--`�-Q� Title ��r� Date 10 <br />FOR D ARTMENT USE ONLY <br />Fee Is Dee: ❑ ANNUALL IZR UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 [1July 1 A Received By July 31 <br />REMIT <br />BILLING <br />BASE EXPLANATION <br />REMITTANCE <br />E <br />AMOUNT DUE <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT_ <br />FEELESS <br />at <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />V10 -L <br />Rece,ved Ey Date Receipt No. Permit No Issuance Date Mailed Delivered <br />