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Applications Will Be Prot• 1 When Submitted Properly Completed. Be Sure"1 Sign The Application. APPLICATION ENVIRONMENTAL HEALTH PERMIT./SERVICES ENGINEER'S ANO/OR IF VEHICLE INVOLVED, GIVE APPLICANT'S AND/OR FOOD ESTABLISPNENTS,MOUSING Make _ CONTRACTOR AND/OR PUBLIC POOLS•WATER SAMPLING BROKER ANO/OR REAL ESTATE INSPECTIONS Lic. No. DENSE AND/OR POULTRY RANCHES AND KENNELS Reg ist. No 3TRATION MISCELLANEOUS SERVICES --- - dER --- Color -- - - -- - - f Application Date t Business/Name To Appear On Permit _ _-_� __ r -• __ - _ -,A Type Permit/Service Requested:_ i APPlicant Name i:JG�"%c,.m C�.. C fir c r'. ; IT,- A dr s �, r < Business Telephone Na Emergency Telephone No.— - CL "'VLocation/Address "'V e Property Owner Address - `• _._ —__ t Operator's Name—: It�, �': __ address <' ) 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOI.ESAi..E ❑ MEAT MARKET ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOL) DEMONSTRATION ❑ FOOD VENDOR ❑ VENDING MACHINES/No.of __ ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE ❑ FOOD CROP HARVESTING/No.of Field Employees --- ALL _-ALL APPLICANTS: Total Employees Including Operators 2. HOUSING 17' ❑ HOTEL/MOTEL/No.of Units ❑ CERTIFICATE OF OCCUPANCY ❑ MOBILE HOME PARK/N,o.of Spaces 3. WATER QUALITY ❑ WATER SAMPLE(Bacterial) ❑ CHEMICAL ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER NO. OF PUBLIC SERVED(Connections) —_ 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds ._—___ -- r :ENNEURunways —__. __..__—. /Animal Population No. No.of Confining Cages Sewage Disposal Method Solid Waste Disposal Method------.— Water ethod—.—_— .—Water pply Source—__ �— Animal Waste Disposal Method 6. FrCONSULTATION FEE ,' . i,i iL 7. ❑ PLAN CHECKING FEE ------ --- S. REAL ESTATE REQUEST: Water Well Inspection 13 Sample 13 Title Company Sewage System Inspection ❑ Address -_ _ Tele. No. Escrow No. ---- -- Seller -_.---- _ Seller Address - Telephone No.___.___ __ —__ Seller Agent Name _ Service Request For Date — — I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances,state laws,and rules and regulations of the San Joaquin Local Health District. APPLICANT'S SIGNATURE X Title, r/1��`� Date_ _ p G I V p FOR DEPARTMENT USE ONLY RSFee Is Due: 11 ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January t 8 Received By January 31 ❑ July 1 &Received By July 31 T REMIT BILLING REMITTANCE f BAS�tt{ 1 LPI N DATE DATE REMITTED AMOUNT DUE CHECKED H�J AMOUNT cQ FEE HEAL ob LESS -- PRORATION PLUS —- ---- - - --- - - ---- PENALTY OTHER OTHER