Laserfiche WebLink
{ <br /> Applications Will Be Ossed When Submitted Properly Completed. Be!To Sign The Application, <br /> • + APPLICATION <br /> ENGINEEF AND./OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> APPLICANT'S AND/OR <br /> C6NTRACTCR AND/OR FOOD ESTABLISHMENTS,HOUSING IF VEHICLE INVOLVED, GIVE <br /> BROKER AND/OR PUBLIC POOLS, WATER SAMPLING ` <br /> Ir'ENSE AND/OR REAL ESTATE INSPECTIONS �- <br /> 3TRATION POULTRY RANCHES AND KENNELS CytNo._____ <br /> I. .BER _ MISCELLANEOUS SERVICES (CORe _ <br /> Color _ <br /> I Application Dale--_____ Business/Name To R <br /> &Type Permit/Service Requeste �[+ Appear On Permit _— <br /> U Applicant Name cf - <br /> ��1L2 hiL Address <br /> Ix _— B mSss Telephone Nor' Emergency Telephone No, <br /> Property Location/Address X' <br /> Property Owner_ ­F1-F,-K.1 <br /> Operator's Name _ �— — AddressC - <br /> - Address <br /> 1. FOOD ESTABLISHMENTS <br /> 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 <br /> C3 ROADSIDE FOOD STAND 1:1 LIQUOR STORE p BAR ❑ BAKERY <br /> El CONFECTIONARY STORE ❑ FOOD SALVAGER 11 ❑ ITINERANT RESTAURANT <br /> ❑ VENDING MACHINES/No. of FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ 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 _ <br /> ❑ MOBILE HOME PARK/No, of Spaces ❑ CERTIFICATE OF OCCUPANCY <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ <br /> NO. OF PUBLIC SERVED (Connections) WATER HAULER <br /> 4. RECREATIONAL HEALTH ❑ —��—� <br /> SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> r 'ENNEL/Runways /Animal Papulation No. <br /> Sewage Disposal Method No. of Confining Cages <br /> Solid Waste Disposal Method_ <br /> Water Sly Source <br /> 6• CONSULTAT}ON FEE — Animal Waste Disposal Metho <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection Sample❑ Title Company <br /> Sewage System Inspection ❑ <br /> Address <br /> Escrow No. �__� -- le. 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 wl a ne in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local th District. <br /> APPLICANT'S SIGNATURE X <br /> ----� Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Dile; ❑ ANNUALLY PER UNIT <br /> ❑ PER SITE ❑ EACH ❑ January I S Received By January 31 El July 1 8 Received By July 31 <br /> BASE E)(PLANATION BILLING REMITTANCE $ REMIT <br /> Ej DATEDATE REMITTED AMOUNT DUE <br /> LLCHECKED <br /> FEE �(J AMOUNT <br /> LESST/Q,/7O <br /> PRORATION v G +, 7- 5 <br /> PLUS <br /> PENALTY PENA.f TICS V^J L B i. I_ z <br /> OTHER <br /> OTHER <br /> Received by DateReceipt Na Permit No <br /> APPLICANT—RETURN ALL COPIES TO: ENytRONMENTAL Y.EALTIi PEAAkIT/SERYI c Issuance Dale Mailed Defiverad <br /> tent c u.�F1 Tnu <br />