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W Applications Will Be Prosed When Submitted Properly Completed. Be SU 0 Sign The Application. <br /> APPLICATION <br /> ENGINEER'S AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES CALTR84 <br /> APPLICANT'S AND/OR <br /> CONTRACTOR AND/OR FOOD ESTABLISHMENTS. HOUSING como <br /> IFVEHICLE INVOLVED, GIVE <br /> BROKER AND/OR PUBLIC POOLS.WATER SAMPIINGICENSE AND/OR REAL ESTATE INSPECTIONSSTRATION POULTRY RANCHES AND KENNELS <br /> I, ,dER MISCEILANF0U5 SERVICES <br /> (Application Date O Business/Name To A <br /> i Type Permit/Service Requested: Appear On Permit — <br /> `Applicant Name <br /> D Ad6ress LV. <br /> & Bu�4�n ass Telephone No. <br /> 'a Property Location/Address SQL`/moo Emergency Telephone No. <br /> `Property Owner <br /> LOperator's Name Address <br /> 1. FOOD ESTABLISHMENTSTotal Address <br /> ❑ RESTAURANT ElFOOD MARKET RETAIL FOOD <br /> SAO Footage Restaurant, Maximum Seating Capacity <br /> FO MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY <br /> ❑ ROADSIDE FOOD STAND 11 LIQUOR STORE 11ARPLANT ❑ BAKERY <br /> ❑ CONFECTIONARY STORE 11 FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ ITINERANT RESTAURANT <br /> ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ FOOD VENDOR <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees VENDING VEHICLE <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 /> r :ENNEL/Runways /Animal Population No. <br /> Sewage Disposal Method No. of Confining Cages <br /> Solid Waste Disposal Method _ <br /> Water S y Source <br /> 6. CONSULTATION FEE Animal Waste Dlgposal Method <br /> 7. 13 PLAN CHECKING FEE `02L`yL <br /> 8. REAL ESTATE V <br /> _ <br /> REQUEST: water Well Inspection[] Sample❑ Title Company <br /> Sewage System Inspection ❑ Address <br /> Escrow No, Tele. No. <br /> Seller <br /> 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 Date _ <br /> FOR DEPARTMENT USE ONLY <br /> Fee I9 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 8 Received By July 3t <br /> BASE EXPLANATION BILLING REMITTANCE S REMIT <br /> /'�� DATE DATE REMITTED AMO D CHECKED <br /> FEE 33,W 5 AMOUNT_ <br /> LESS <br /> PRORATION <br /> PLUS PE <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Recewed by Date — cipt No Permil No <br /> APPLICANT—RETURN ALL COPIES TO! ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.I HAZELTONtAVE,P.O.9o.2009 OICKTON,CA 95201 <br />