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' Applications Will Be P _^eased When Submitted Properly Completed. Be",ire To Sign The Application. <br /> APPLICATION <br /> r <br /> 'ENGINEER'S AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR PUBLIC POOLS•WATER SAMPLING Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONS <br /> IrF_NSE3TR AND/OR POULTRY RANCHES AND KENNELS <br /> 1. dER LiC. No. <br /> iTRgT10N MISCELLANEOUS SERVICES Regist. No. <br /> _ <br /> � 1�Color <br /> FApplication Date — Business/Name To AP On Permit � �5 LAI V1 O13 @,jTjq{, Cgn�� "C <br /> FI Type Permit/Service Requested: to <br /> S <br /> A licant Na e 7A ddress 0 <br /> u 5 , <br /> i <br /> Bus i s Telephone No. 4([��7g7 ?I 10 Emergency Telephone No,( 1 '- /Orf <br /> /Property Location/Address <br /> d Property Owner r P4A I Address ' Z <br /> -Operator's Name `` Address ' r <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT M <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BA li <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITIN T RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOO VENDOR <br /> ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDINrUQiltlQ 1990 <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators HEALTH <br /> 2. HOUSING EN F��js�CES <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL �O <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 /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> r .ENNEL/Runways /Animal Papulation No. No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Suppiy Source ._ Animal Waste Disposal Method <br /> 6. ❑ CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE <br /> S. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample 13 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 h repared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a ales and regal 'ams of the S Joa Local Health District. <br /> APPLICANT'S SIGNATURE X itle \ Date o-.2c) <br /> FOR PAT E SE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 0 PER SITE ❑ EACH ❑ January 1 R Received By January 31 ❑ July 1 3 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DAMOUNT DUE CHECKED <br /> ATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No Issuance Date Mailed Delivered <br /> APPI lrANt—OFTI IRN At L f_OPIES TO'. ENVIR0NMFNTA1 HFAt TH PFRMITfSERVICES 1601 E HA717LTON AVE. PO A—9nna cTnCa TnN r,aa9nt <br />