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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ✓IRONMENTAL HEALTH PERM IT/SERVI„-S <br /> ENGINEER'S AND/OR D;q <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING a <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING BROKER AND/OR REAL ESTATE INSPECTIONS ic. NIrENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES t ----- <br /> 1. .BER __-_ Color —_- <br /> f Application Date - _._- _.__.._ Business/Name To Appear On Permit <br /> m Type Permit/Service Re uested __._ --. _-_._-... .. . .. _.____. - --P--.-- <br /> - _ _ _-B-_o___3_3 <br /> _ _ _ <br /> Applicant Name __ RAH Environmental — _ Address.-.--P.- 0. x 11, Citrus Fei gFts�3b�_1 <br /> Busine$s Telephone No. _-__ -. -__ - —.- Emergency Telephone No. <br /> <Property Location/Address .14700 S1I1U1 to RC1. , Trac <br /> Owens Illinois <br /> a Property Owner- _ -__ Address <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 ❑ LIOUOR 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 /> r '.ENNEL/Runways _._.___ /Animal Population No. —__ --_ _ No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source - Animal Waste Disposal Method <br /> 6. U CONSULTATION FEE Consultation Review <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. 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 A Received By January 31 ❑ July 1 A Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE E <br /> BASE EXPLANATION DAMOUNT DUE -�CKED <br /> ATE DATE REMITTED <br /> AMVU <br /> 1=1Qllrs — <br /> FEE _. $175.00....__.__ 4$70.00 $105.00 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY P NAI-TIriA-4ljt B[ <br /> OTHER D ;npoli�F6 <br /> 0PAST DUE CCOUNTS 0 <br /> rS f ItUMQ ILICLC:� ' E,OTHER <br /> - •� ��]_--- <br /> ll <br /> /ed by I ale Receipt No Per it No Issuance ate Mailed Delivered <br /> ,f Pnl 11•-11 .RF^•e`• 'l 1. InIl cTn a 11. nNMFUrrll .Fl11 TN PF .•T,<enl lrr< tar {♦ n r - -^ <br />