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u <br />'ENGINEER'S AND/OR <br />APPLICANT'S AND/OR <br />CONTRACTOR AND/OR <br />BROKER AND/OR <br />.1('ENSE AND/OR <br />"—ATION <br />Appitcation§ Will Be PJIJMed Whew Submitted Properly Completed. Be Allhf6To Sign The Appiicta.. <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 />IF VEHICLE INVOLVED, GIVE <br />Make <br />LIc. No. <br />Regist. No. <br />'I.. , .BER Color <br />Application Date Business/Name To Appear On Permit kt^or���� <br />ri,Type:Permit/Service Requested <br />a Applicant Name Address' <br />J usiness Telephone No. Emergency Telephone No. <br />Qproperty Location/Address 0C <br />aProperty Owner Address <br />-Operator's Name be r r Address <br />1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br />❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br />11 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 />11 VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br />13 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 11 WATER SAMPLE (Bacterial) ❑ CHEMICAL <br />11 PUBLIC WATER SYSTEM SURFACE WATER SUPPLY ❑ WATER HAULER <br />NO. OF PUBLIC SERVED (Connections) <br />4. RECREATIONAL HEALTH 11 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 <br />7. ❑ PLAN CHECKING FEE <br />8. REAL ESTATE <br />REQUEST:1W ter Well Inspection❑ Sample❑ Title Company <br />.,Nape System Inspection ❑ Address Tele. No. <br />S No. <br />lone No. <br />e Request For Date <br />Seiler Address <br />Seller Agent Name <br />certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br />:es, state and rules and regulations of San Joaquin Local Health District. <br />APPLICANT'S SIGNATURE X � G Title Date _ <br />• • � - . 3��7:I41 <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 />/ 0 <br />7ko <br />7 <br />r 7 <br />LESS <br />PRORATION' <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />Received by Date R No. Permit No. Issuan 4e Mailed Delivered <br />• • � - . 3��7:I41 <br />