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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINE EP 5 AND UN IF VEHICLE INVOLVED, GIVE <br /> APPLICANTS AND'OR FOOD ESTABLISHMENTS.MOUSING Make —__ -- ------ <br /> 'ONTAACTCrn AND on PUBLIC POOLS WATER SAMPLING <br /> REAL ESTATE INSPECTIONS LIC. NO <br /> I,uOKER ANT,r�rr __------ -- - - <br /> POULTRY RANCHES AND KENNELS <br /> cr,iE Arri.I)F1 Reglst NO _ ---- ------- <br /> ;raA Nt , MISCELLANEOUS SERVICES <br /> Color - <br /> r.E N <br /> /I'PI , Allo„ f),tc 1-1.3-rib Business/Name To Appear On Permit <br /> TyP(. Pi,,n,.; Servu:e Requestec XEROX COPIES 2041 Navy Dr . , & 1330 Field, Stkn <br /> ` AppwCAnIName Attornevs Diversified ServiCe`*,dd,ess 545 N . California , Stkn <br /> U Business Telephone No 943-6110 Emergency Telephone No <br /> a i'rr,l-fly LI_mio n Address <br /> a <br /> Address <br /> ` Address <br /> it n!r,,tUr 5 Namt! <br /> 1. FOOD ESTABLISHMENTS Total Building Sq Footage Restaurant. Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MECFD <br /> OVO <br /> ❑ FOOL) PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ PR <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ A <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ <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 /> 1:1HOTEL MOTEL/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 /> o. 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 Population No _ No. of Confining Cages <br /> Sewage Disposal Method - —-""---"-- <br /> Solid Waste Disposal Method - - <br /> Water SuPPIY Source --- - <br /> Animal Waste Disposal Method <br /> ---- - - <br /> 6. ❑ CONSULTATION FEE ----- <br /> 7. ❑ PLAN CHECKING FEE -- -------- -- -- <br /> 8. 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 <br /> ___Telephone No Seller Agent Name - - ------- <br /> Service <br /> -----Service Request For Date <br /> I hereby certify that 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 /> APPLICANTS SIGNATURE X _ -" ------------- - - -- ---- Title_—__ _ Date <br /> FOR DEPARTME!'T USE ONLY <br /> Fee Is Due: ❑ f ANNUALLY ❑ PER UNIT ❑ PER SITE El EACH ❑ January T 6 Received By January 31 C] July 1 S Received By July 31 <br /> _ ___T----- REMIT BILLING REMITTANCE s AMOUNT DUE CHECKED <br /> BASE— EXPLANATION <br /> DATE DATE REMITTED AMOUNT <br /> FEE �c �e�ie�v�-.eMy ley-.—� �• <br /> LESS staple a d return tO file. <br /> PRORATION + <br /> PLUS <br /> PENALTY <br /> OTHER —I 33.90_ - _- _339-_@.lb__ ___ $63 .90 _ <br /> OTHER ��•�� <br />