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Applications Will Be P. ssed When Submitted Properly Completed. Be To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEERS AND OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANTS AND OR FOOD ESTABLISHMENTS. MOUSING Make <br /> CONTRACTOR AND OR PUBLIC POOLS. WATER SAMPLING - <br /> BROKER AND OR REAL ESTATE INSPECTIONS LIC No <br /> ,rFNSE AND OR POULTRY RANCHES AND KENNELS <br /> ;TRATION MISCELLANEOUS SERVICFS Reglst NO <br /> dER Color <br /> Application Date Busmess'Name To Appear On Permit <br /> (aType Permit'ServlCe Requested - <br /> i Applicant Name Address <br /> Business Telephone No Emergency Telephone No. <br /> Property Location Ad <br /> Property Owner( � ��r��X� Address <br /> Operator 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 /> ❑ HOTEUMOTEUNo 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 /> waupply Source Imat Waste Dls o I Method <br /> ter <br /> 6 CONSULTATION FEE --- <br /> 7 ❑ PLAN CHECKING FEE - -- - - <br /> 8. REAL ESTATE <br /> REQUEST Water Well Inspection C3 Sample C3 Title Company <br /> Sewage System Inspection ❑ Address Tele No <br /> Escrow No <br /> Seller Seller Address <br /> Telephone No yeller Agent Name <br /> Service Request For Date <br /> I hereby certify that I have prepared this appIIcat n and that the work will be done in accordance with San Joaquin County <br /> ordinances. state laws, and rules and regulations T he San Joaquin Local Health District. <br /> It"' <br /> pp <br /> APPLICANTS SIGNATURE X Title _ ___- __ Date <br /> 7 FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY_ _❑ P _1/W-7, ❑ PER SITE _ACH ❑ January 1 &Received By January 31 f ❑ July 1 &Received By July 31 <br /> _ - - - -- - REMIT <br /> RASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE .CHECKED <br /> DA DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> OLUS <br /> 'ENAI.TY — - <br /> THEIR L <br /> HER. - �-- ----- --—I -- <br /> ved by Date HPcerpt No Permit No Issuance Date Mailed Delivered <br /> --- '"'._ ..._�.�.... ...� .... r__.www �rnl-rrn�. ��men• - <br />