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Applications WIII Be I tasted When Submitted Properly Completed. Be To Sign The Application. <br /> 'W1 APPLICATION �w <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS. HOUSING Make _ <br /> CONTRACTOR AND/OR PUBLIC POOLS WATER SAMPLING -------'------ - <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. NO. <br /> irRNSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> I. .BER __ _.._.._ __ - . ... . .. Color <br /> [Application Date /__—Q_�-� BUsi I ness/NarW To Appear On Permit <br /> w Type Permit/Service Requested: <br /> i Applicant Name .__ Address <br /> Business Telephone No. —.._—____.___ Emergency Telephone No.— —. <br /> %Property Location/Address _ <br /> /Property Owner_ __ _ __—.. ---- Address <br /> (Operator's Name Address ----.-- <br /> 1. <br /> ddress ___.--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 D= AYMENT <br /> OOD VENDOR <br /> ❑ VENDING MACHINES/No. of _. ❑ MOBILEENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/ o. Field Employees _- ___.___-__... __ s <br /> ALL APPLICANTS: Total E pl a ncluding Operators—__ ____ _._____ <br /> z. HOUSING pppp�+ <br /> ❑ HOTEL/MOTEL/No. of _ ❑ CERTIFICATE OF OCCLJPRNCY E I V E D <br /> ❑ MOBILE HOME PARK/ of Spaces JAN <br /> 11 <br /> 3. WATER QUALITY WATER SAMPLE (Bacterial) 11 CHEMICAL JAN <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) ___ ___— _ ENVIRONMENT <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BARERI"UTgLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARMi Maximum No. of Birds — --_ _ <br /> i 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 /> S. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ SampleI3 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 /> v 1 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 'ulea and Legulations of the San Joaquin Local Health District. <br /> 7 <br /> APPLICANT'S SIGNATURE X Grh 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 /> BASE EXPLANATION BILLING REMITTANCE $ <br /> AMOUNTDUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 35 CJ6 f�.d� <br /> LESS 1 <br /> PRORATION J <br /> PLUS <br /> PENALTY <br /> OTHER —� -- -_-- <br /> OTHER --- <br /> . <br /> Received by Date eipt No. Perms No. Issuan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PFRMIT/SERVIrFS 1Ad1 F ".IF,VA..,IF en e...v . mnnavnu ns seem____ <br />