Laserfiche WebLink
ENGINEER'S AND/OR <br />APPLICANT'S AND/OR <br />CONTRACTOR AND/OR <br />BROKER AND/OR <br />LICENSE ANO/OR <br />REGISTRATION <br />NUMBER <br />-- <br />Applications Will Be Prxessed When Submitted Properly Completed. Be Sure To Sign The Application. <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />FOOD ESTABLISHMENTS, HOUSING <br />PUBLIC POOLS. WATER SAMPLING <br />REAL ESTATE INSPECTIONS <br />POULTRY RANCHES AND KENNELS <br />MISCELLANEOUS SERVICES <br />GENERAL <br />IF VEHICLE INVOLVED, GIVE <br />Makes <br />Lid. No. <br />Regist. No. <br />Color <br />[Appl[Application <br />ication Date Business/Name To Appear On Permit--- <br />pType Permit/Service Requested: <br />`Applicant Name Western e� ologic �SDUrceS9 Inc. —Address ��8 T�eadldnc�s fit:dU- salit09�5 <br />_ Business Telephone No. —_ —__ Emergency Telephone No. — <br />(Property Location/Address 2905 W. RPtlldml n H�Lt _�r�- Stkn _— - — <br />iProperty Owner _— Address_— <br />L 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 />❑ HOTEL/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 />A. RECREATIONAL HEALTH 11 SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br />5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br />❑ KENNEVRunways /Animal Population No. No. of Confining Cages <br />Sewage Disposal Method <br />Cn1iA Waata rliannaai MwthM <br />Water Supply Source Animal Waste Disposal Method <br />8. =CONSULTATION FEE UGST-CONSULTATION REVIE® BUSINESS LICENSE <br />7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <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 No. Seller Agent Name <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 />APPLICANT'S SIGNATURE X Title <br />Date <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 6 Received By January 31 ❑ July 1 & Received By July 31 <br />- REMIT -- <br />BASE EXPLANATION <br />BILLING <br />REMITTANCE' <br />$ <br />AMOUNT DUE <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEE <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />9.00 Penal ty <br />4/3/89 <br />$99.00 <br />OTHER <br />OTHER <br />i <br />Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br />•nol Ir•�MT_oFTI mM •11 e-nDMA Tn• HIIIII&MYFMTAI 14FAI TM PFP1LAIT/aFOV1r`Fa an, F MAjillftbM AVF P n ft— am nrnrgTna rA M'M, <br />mr IF <br />f <br />