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y <br />ENGINEER'S AND/OR <br />APPLICANT'S AND/OR <br />CONTRACTOR AND/OR <br />BROKER AND/OR <br />WENSE AND/OR <br />3TRATION <br />I. .BER ___---- <br />Applications Will Be P ed When Submitted Properly Completed. Be S 0 <br />Sign The Application. <br />APPLICATION <br />LICATION <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 />IF VEHICLE INVOLVED, GIVE <br />Make <br />Lic. No. <br />Regist. No. <br />Color <br />[Application Date 2W99 Business/Name To Appear On Permit — — <br />Type Permit/Service Requested:: <br />ApplicantWf S Name _-�i S� 1 C-_ Address <br />n� g �lAl"NDS L7L� <br />old -A X4(05 Business Teleph ne No Emergency Telephone No. <br />aProperty Location/Addre s <br /><Property Owner _ Address <br />LOperator'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 />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 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 ST - uL I- 1�9 <br />7. PLAN CHECKING FEE <br />E. 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 <br />Title <br />Date <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & Received By January 31 ❑ July 1 & Received By July 31 <br />REMIT <br />BASE <br />EXPLANATION <br />BILLING <br />REMITTANCE <br />$ <br />AMOUNT DUE <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEE <br />pp���{� <br />�1W <br />G <br />l / <br />I —21a� t�q <br />y�-� <br />.e.rJ <br />LESS. <br />tin <br />PRORATION <br />PLUS <br />g` <br />DAYS Fr-) <br />j'yr'` UNG <br />PENALTY <br />OTHEROr <br />ter/ ✓V <br />6a2, <br />b0 <br />2/16/89 <br />OTHER <br />Received by Date Receipt No. Permit No Is'sN9ce Date Mailed Delivered <br />. _... ..,...� ....e. ..... ... w__. - v....,n......ru>.. .,r.,.., nr nu.r.er.I-- tem r uw>o rnu wVC on a... m.no av^K Vv^u ra aS9a1 <br />