FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

f Applications Will Be Pr, sed When Submitted Properly Completed. Be Sr To Sign The Application. APPLICATION ENVIRONMENTAL HEALTH PERMIT/SERVICES ENGINEER'S AND/OR APPLICANT'S AND/OR CONTRACTOR AND/OR BROKER AND/OR IrFNSE AND/OR 3TRATION I. .BER —------- --- F000 ESTABLISHMENTS, HOUSING PUBLIC POOLS, WATER SAMPLING REAL ESTATE INSPECTIONS POULTRY RANCHES AND KENNELS MISCELLANEOUS SERYICIFS IF VEHICLE INVOLVED, GIVE Make _ _ Lic. No. Regist. No. Color (Application Date _�.��Business/Name To Appear On Permit caType Permit/Service Requested:ji� _ a A licant Name —_>�? -[�! v��-51_L�_-.__ Ad ess `T_(__iQ _T_`T_ 1 u d — 75 --� �-I -3 - Bu?�jiness�Telephone NoC41� q -a4-�_ Emergency Telephone No. a rt Location/ ddre Property Owner __ p_��rrr��-`z Address (Operator's Name _. I pP� ��L Q`�Address --- — 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR ❑ 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 PLACE 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds r :ENNEL/Runways _ /Animal Population No. No. of Confining Cages Sewage Disposal Method Solid Waste Disposal Method _ Water Supply Source --- ___ Animal Waste Disposal Method 6. CONSULTATION FEE S r LEO 7. ❑ PLAN CHECKING FEE 8. REAL ESTATE REQUEST: Water Well Inspection Sample Title Company Sewage System Inspection ❑ Address Tele. No. Escrow 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, and rules and regulations of the San Joaquin Local Health District. APPLICANT'S SIGNATURE X Title Date FOR DEPARTMENT USE ONLY Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I.& Received By January 31 ❑ July 1 & Received By July 31 BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE REMIT CHECKED DATE DATE REMITTED AMOUNT FEE t DUE PCCOUNIS 3-) LESSPRORATION i./ I J I ItVIVI bj LI;VG DATE. PLUS PENALTY OTHER�I 21 O OTHER Received by Date Receipt No Permit No. Issuance Date Mailed Delivered