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Applications Will Be Fired When Submitted Properly Completed. Be Sua Sign The Application. <br /> APPLICATION a <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.MOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING - - - - <br /> BROKER AND/OR REAL ESTATE INSPECTIONS LIC. No. . ___—_.— <br /> irENSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TRATION MISCELLANEOUS SERVICES ----"—"' <br /> I. .BER _______.._____- Color <br /> f Application Date_-� B Iness/Ny�am a To pear On Permit IYiIG�C .��5 <br /> vl Type Permit/Servic RRe-quested: F-Cy — ------ 0�/11��� pp <br /> Applicant Name ��' �' T�4 !7'bs Address.-�� ROX 90/17)? �t1 - '?5269 <br /> i — Business Telephone NZ2� —e.f—(�� Emergency Telephone No. <br /> °a Property Location/Address_ <br /> a <br /> Property Owner ___ _ _—___ Address <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 ❑ 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 /> Watr Supply Source _ Animal Waste Disposal Method <br /> 6. CONSULTATION FEE <br /> 7. .PLAN CHECKING FEE <br /> B. 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 1 A Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT_ <br /> ao <br /> FEE �- <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 3 <br /> Received by Date Receipt No Permil No. lesuance Date Mailed Delivered <br /> ........-.— --.,— c..—.....— ..ce 1..eeeunieeeviree 1.1 a ueser rnu eve o 01 o...Dora ernr¢rnu rA osfm <br />