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illb <br /> I Appllcations Will Be Pred When Submitted Properly Completed. Be S o Sign The Application. <br /> 0 APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S ANDIOR FOOO ESTABLISHMENTS,HOUSING Make — <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING ---"-- <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. — <br /> JrPNSE AND/OR POULTRY RANCHES MNO KENNELS Re St. No. <br /> 3TRATION MISCELLANEOUS SERVICES g ----- <br /> i. .dEA __.__— p Color — <br /> f Application Date Q_ o^.-(0 Busine /Na To Appear On Permit <br /> mType Permit/Service R quested: PA, . JGYLSInzpCr <br /> a Applicant Name — "/I �q� � <br /> U <br /> ss Tel ne No."- --- . Emergency Telephone No. <br /> `Property Location/Address 41 <br /> ,, <br /> J Property Owner—1� 1/'rL�✓L� K • -S —__ Address 2��!' /M-a Q��YU I 'I- <br /> LOperator'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 /> S. VECTOR CONTROL Cl 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. ❑ CONSULTATION FEE <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/ A Received By July 31 <br /> REMIT <br /> BASE EXPLANATION 1�9T%P90 <br /> REMITTANCE REMITTED AMO CHECKED <br /> A AMOUNT_ <br /> FEE <br /> LESS $ JD <br /> PRORATION /—_ <br /> PLUS <br /> PENALTY ^ <br /> OTHER r' <br /> , ^,'.'�:i":.� 'A'II_L GAPPL1L(� <br /> D�� <br /> ntvl 81i <br /> OTHER .NGL T . <br /> Received by Date 7W.,pt No Permit No Issu ate Mailed Delivered <br />