Laserfiche WebLink
it Applications Will Be 0ssed When Submitted Properly Completed. Be 0 To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF I INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> CONTRACTOR AND/OR PUBLIC POOLS„WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS N <br /> irENSE AND/OR POULTRY RANCHES AND KENNELS Re ISI. <br /> STRATION MISCELLANEOUS SERVICES 9 -- <br /> (a <br /> 1, 6ER --__---- Color <br /> f Application Date Business/Name To Appear On Permit <br /> ,aType Permit/Service Requested,z. /7 <br /> UApplicant Name<45au_(�i 1 `r"41f�7� -- Address 1 �ft r il�. ►L�. , – <br /> B mss Telephone Nom Emergency Telephone No. <br /> i Property Location/Address <br /> aProperty Owner ___ --�_�� -_- f Address 0� � �a ' r <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 <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 Stipply Source _ Animal Waste Disposal Method <br /> op <br /> 6. CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE <br /> 6. 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 Title 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 /> BILLING REMITTANCE $ REMIT <br /> SASE EXPLANATION DATE DATE REMITTED AMOUNTDUE CHECKED <br /> ? <br /> M- <br /> AMOUNT <br /> FEE �` CP f��go <br /> LESS 5 - - <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER PENALTIES VP �B[ � Ir- <br /> OTHER f { C�r'VI I LING DA <br /> Received by _ Dale flecvipt No Permil No Issuance Date Mailed Delivered <br /> APPLICANT—RETIJ R N ALL COPIES TO! ENVIRONMENTAL HEALTH PERM I <br />