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Applications WRI Be Prod When Submitted Properly Completed. Be Su0Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S ANDIOR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> tiROKER AND/OR REAL ESTATE INSPECTIONS (0t, <br /> ICENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION �f MISCELLANEOUS SEHWIC(S '� O. <br /> ---U— <br /> I. Color <br /> Application Date Business/Name To Appear On Permit — <br /> oType Permit/Service Requested: r �� <br /> K ApPlic nt ame(��,(1- �D A/ ��[3! / 2-11 Address R'3 77-- <br /> a �� �__9� 1Jjmess Telephone No. Emergency Telephone No. <br /> Properly Location/Address; Y`� Yi9 �LG? <br /> Property OwnereV_1�_..._,.__._l y►_+ h rL Address �G '1dnL _ <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 13 ITINERANT RESTAURANT <br /> CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION 1:1 FOOD VENDOR <br /> ❑ VENDING MACHINES/No.of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/ND. 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 <br /> S,4wly Source Animal Waste Disposal Method <br /> 6. CONSULTATION FEE _ 1� - y�zi�. Gr �? _ G !� <br /> T. ❑ PLAN CHECKING FEEn_.___..:� + <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 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 h Received By January 31 ❑ July 1 &Received Ry July 31 <br /> BILLING REMITTANCE i REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE $105.00 3 hrs, '..2/12/90 $105.00 ---- <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY PFNALT ES WILL BE A_ PLIED T_ Q PA T D�1F ACC UMTS 30 <br /> OTHER DAYS F OM BILLING BATE. <br /> OTHER <br /> Rucetvud Ly DAIu RuGnpl No. F'uunit No Issuance Dale Madud Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />