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r <br />ENGINEER'S AND/OR <br />APPLICANT'S AND/OR <br />CONTRACTOR AND/OF <br />BROKER AND/OR <br />.ir'ENSE AND/OR <br />3TRATION <br />I, .8ER <br />iApplication Date _- <br />oType PermitiServlc <br />Applicant Name <br />Applicatlns Will Be Pr ed When Submitted Properly Completed. Be Suina.To Sign The Application. <br />APPLICATION-.�. • <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />FOOD 'ESTABLISHMENTS. HOUSING IF VEHICLE INVOLVED, GIVE <br />PUBLIC POOLS, WATER SAMPLING Make <br />REAL ESTATE INSPECTIONS Lic. No.,_— <br />POULTRY RANCHES AND KENNELS Regist. No..-.-- <br />MISCELLANEOUS SERVICES--- - <br />Color <br />Business/Name To Appear On Permit <br />Requested:- — � _ �'_�._- _ __._�%--✓"-- __ <br />411 � <br />— Address <br />Property Location/Address <br />aProperty Owner �,�/, _ / -... Address <br />LOperator's Name -- __"-__---- --- Address <br />1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br />RESTAURANT 0 FOOD MARKET RETAIL 0 -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 11 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 0 SURFACE WATER SUPPLY WATER HAULER <br />NO, OF PUBLIC SERVED (Connections)` <br />4. RECREATIONAL HEALTH ❑ SWIMMINGPOOL❑ SPA 11 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 />-Sewa9e Disposal Method <br />Solid Waste Di poral Method — <br />Water Sta y Source _ Animal Waste Disposal Method <br />6. ONSLTATIN FEE'' <br />7. 0 PLAN CHECKING FEE <br />8. REAL ESTATE y <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 t oftafielland that the work will be done in accordance with San Joaquin County <br />ordinances, state la and r les an ons -1 'the San Joaquin Local HealthDistrict. <br />APPLICANT'S SIGNATURE X Tit .- Date <br />FOR DEPARTMENT USE ONLY <br />Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t & 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 />YN1/lZr <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />0 <br />OTHER <br />/v - d 1� <br />Received by Date IRMPeceipt No. Permit No. Issu ce Date Mailed Delivered <br />_ __-__.- ___""_'. ... _.__-____...s:........:.................w.....®,.....:,:.+�.. .�.aa eu. :rs tine .vr •an ®_.. ..nne-'. evnrvrnu CA <br />