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f <br /> Applications Will Be FIT ed When Submitted Properly Completed. Be Sino Sign The Applicolton. <br /> ` APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> IF VEHICLE INVOLVED, GIVE <br /> ENGINEERS AND,OR FOOD ESTABLISHMENTS.HOUSING <br /> APPLICANTS ANDIOR Make __— -- <br /> CONTRACTOR AND OR PUBLIC POOLS WATER SAMPLING <br /> REAL ESTATE INSPECTIONS Lic. NO. _ <br /> BROACA AND OR POULTRY RANCHES AND KENNELS <br /> irENSE AND OR Regist. No. _ <br /> STRATION MISCELLANEOUS SERVICES Color --- <br /> dER <br /> Appl�CahOn Date 1-13-88 Business/Name To Appear On Permit - ------ - - <br /> XEROX COPIES '1041 Navy Dr . , & 1830 Field, Stkn <br /> ,Type PerService Req 845 N . California, Stkn <br /> ADDhcantNa Name Attornmee ys. lliversified Service�,edress _ - ------ --- <br /> u Business Telephone No. 943-6110 Emergency Telephone No. --------- <br /> e Property Locahn <br /> o .•Address <br /> Property Owner Address <br /> Operator's Name Address <br /> f. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEA RQ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT D❑ AK❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ RAI{T❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ F D �J <br /> ❑ VENDING MACHINES/NO. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTINGINO. of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING <br /> ❑ HOTELfMOTEL/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 /> A. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds -- <br /> F .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 /> 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 ;hat 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 DUI: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH January 1 a RT ewetl By January JI ❑ July I A Rece,�eG By July 71 <br /> T---- REMIT <br /> BASE l EXPLANATION BILLING REMITTANCE f AMOUNT DUE CHECKED <br /> DATE DATE l REMITTED AMOUNT <br /> FEE._ .... . .._�,..$ >/O.0_ �$1.01_hr. Icesie. � e�D_Y� Px;--ra�.la. --_— <br /> LESS ! staple and return to file. <br /> PRORATION <br /> PLUS <br /> _ 33.90 339 lb �, $63, 90 - --- -- <br /> PENALTY <br /> OTHER <br /> L,7 d <br /> - — <br />