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Appilcallons Will Be Processed When Submitted Properly Cc 1ple#ed. Be Sur�oA Slgr. "*he Application. APPLICATION r G S M L � ,�..' ENVIRONMENTAL HEALTH PERMIT/SERVICES APPIENCs'NGu♦R,'S ANCA'OR C1-'N+CANTL)R'AN.,O FOOD ESTABLISHMENTS,HOUSING IF VEHICLE INVOLVED, GIVE 8ROXER AND/ AND.�O;1 PUBLIC POOLS,WATER SAMPLING Make 8ROXER AND/OR REAL ESTATE INSPECTIONS rr NSE AND/OH POULTRY RANCHES AND KENNELS LfC. No. 3TRATIOId ---------_ I, .dER ...-_. .._ MISCELLANEOUS SERVICES Regist. No. Color Application Date j� -�- i /---- - Business/Name To Ap ea -_. On Permit ` ,M CilrvI ,n Type Permit/Service Requested f w- ani U Applicant Name d - _ Address - - - -------_-_ Business TelephoneN Emergency Telephone No. 'I Property Location/Ad ress �`1U� -Akj*��/ c Property OwnerlC - p- Addresst'64 - Operator's Namev✓i -+�� _ �ra._2"r.�_ -• j � �e 7 -- - Immilq- Address 1. FOOD ESTABLISHMENTS Total Building Sq. Footage 1:1 RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE Maximum Seating Capacity ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT MEAT MARKET El ROADSIDE FOOD STAND ❑ LIQUOR STORE El BAR BAKERY ❑ CONFECTIONARY STORE C1 FOOD SALVAGFR ❑ FOOD DEMONSTRATION ❑ FOOD ITINERANT OR TAURANT ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE ❑ FOOD CROP HARVESTING/No. of Field Employees _ ALL APPLICANTS: Total Employees Including Operators 2. HOUSING ❑ HOTEL/MOTEL/No of Units ❑ CERTIFICATE OF OCCUPANCY ❑ MOBILE HOME PARK/No. of Spaces 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER NO. OF PUBLIC SERVED (Connections) 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLAt 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds t r :ENNEL/Runways /Animal Population No. No. of Confining Cages Sewage Disposal Method - Solid Waste Disposal Method Water Supply Source _ _ 6,/t< CONSULTATION FEE :RS e^-^ AnimaP Waste Disposal Method 7. ❑ PLAN CHECKING FEE D. REAL ESTATE REQUEST: Water Well Inspection❑ Sample❑ Title Company Sewage System Inspection ❑ Address �- Escrow No. _._ Tele. No. Seller .__� -`_ Seller Address Telephone No.-.._� - Seller Agent Name Service Request For Date I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, an ru es and regulla ions of the San Joaquin Local Health District. APPLICANT'S SIGNATURE X —Xf-L 44- f Title�c 1S' Date FOR DEPARTMENT USE ONLY +/ Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BASE EXPLANATION BILLING REMITTANCE $ REMIT _ DATE DATE REMITTED AMOUNT DUE CHECKED FEE 3 lV AMOUNT LESS PRORATION PLUS PENALTY OTHER _ OTHER — _ C LkReceived bye — 1---� Aeceipl No Perron No APPLICANT— TI Iissuance Date ;