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Applications Will Be F`1•ssed When Submitted Properly Completed. Be �: To Sign The Application. APPLICATION ENVIRONMENTAL HEALTH PERMIT/SERVICES ENGINEERS AND OR IF VEHICLE INVOLVED, GIVE APPLICANTS AND.OR F000 ESTABLISHMENTS. HOUSING Make CONTRACTOR AND OR PUBLIC POOLS, WATER SAMPLING — BROKER AND OR REAL ESTATE INSPECTIONS LIC No ENSE ANO,OR POULTRY RANCHES AND KENNELS RB ISI NO�_.�__- 3TRATION MISCELLANEOUS SERVICES g - -- aER ---�. COIOf Apphcatlon Date3 -- Byslness,Name To Appear On Permit ----- ---- --------------- ---- - - --- �Type Permit/Service Requested Ze Applicant Name Address - Business Telephone No -_ ____. Emergency Telephone No. Property Location/Address - - - —-— --- -- ------ -- (Property Owner _ _ Address -- _-- --- _---- _- -- - _-------_- Operator s Name --- Address -- - ---- - ----- -- -- - t. 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 ❑ MOTEL/MOTEL/No Of Units _____ - ❑ CERTIFICATE OF OCCUPANCY ❑ MOBILE HOME PARK/No of Spaces 3. WATER OUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER NO OF PUBLIC SERVED (Connections) __-_--- 4. RECREATIONAL HEALTH ❑ SY41MMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE C S. 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 Anima. Waste isp sal Method 6CONSULTATION FEE 6 __ 7 PLAN CHECKING FEE - - --- - --- ---- - a. REAL ESTATE REQUEST Water Well Inspection❑ Sample❑ Title Companyf, Sewage System Inspection ❑ Address Escrow No - --- - Seller Seller Address Telephone No Seller Agent Name Service Request For Date I hereby certify that I have prepared this applicati and that the work will be done in accordance with San, .Joaquin County ordinances, state laws / , APPLICANTS SIGNATURE X Title , Date I FOR DEPARTMENT USE ONLY Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 4 Received By July BILLING REMITTANCE�- S REMIT --- BASE J P A TION I - — —� — i AMOUNT OUE CHEC DATE DATE REMITTED Ar FEE -- LESS PRORATION PWS -- PENALTY OTHER OTHER -- _ - --- -- -- I - --- Qe0CK ON.CA Raeawed by Dace- - - -—----Receipt No —" Permit No �.............�.._.. ..�..�....�.....�,��e.,..-« 445 N.