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Applications Will Be Procs When Submitted Properly Completed. Be Sur 4ign The Application. <br /> PAYMqj*TAPPLICATION <br /> `, E�RONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'$.RND/OR 'E MELZ IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING .Make - <br /> CONTRACTOR AND/OR O.ap PUBLIC POOLS.WATER SAMPLING -- - - <br /> @RAKER AND/OR n C T 2 9 1988 REAL ESTATE INSPECTIONS Lic. NO. . <br /> .DENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION SAN JOAQUIN C&_ MISCELLANEOUS SERVICES Regist. No. <br /> 1, .8ER _PIJP'..IC HEALTH SFr.^�.;;'.. <br /> Color <br /> V <br /> / ENV R"NMENTAL HEALTH DIVISiGN <br /> [Application Date 0 Business/Name To;,Aear On Permit r <br /> FI Type Permit/Service eques d: /tiDi1.C10J.U_ <br /> a Applicant NameAa dd ress � 7 � n <br /> M T� f([An� Business Telephone No. Emergent Tele hone No. <br /> `Property Location/A dress �- <br /> `Property Owner_�..-�¢_V ___L 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 ❑ 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 /> 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. ❑ CPNSULTATON FEE ,,// ."^� '- - <br /> 7. ®/PLAN CHECKING FEE /,;l 5 T�, l <br /> 8. REAL ESTATE OO _ <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 w r will b one in accordance with San Joaquin County <br /> ordinances, state laws, jqd rules and regulations of the Sen oaquin L I Hea istriicct. <br /> APPLICANT'S SIGNATURE X - if ' Date <br /> Title �� b �-2W'- bt/ <br /> N T� <br /> FOR DEPARTME U NLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH anuary 1 A Received By January 31 ❑ July 1 A Received By July 31 <br /> BILLING REMI T E $ REMIT <br /> BASE EXPLANATION DATE TE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT_ <br /> FEE <br /> LESS 7.✓50 <br /> PRORATION r <br /> PLUS <br /> PENALTY a, <br /> OTHER <br /> 10117190 <br /> OTHER <br /> DAYS FROM 'NG U ` { I E ACCOUNTS 30 <br /> Received by Date lWipt No. Permit No. Iss Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA ON AVE_Ro.ee.MM Rrocxmu nA aaam <br />