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Applications Will Be P—1111—d When Submitted Properly Completed. Be SSign The Application. <br />4W APPLICATION 0 <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br />APPLICANT'S AND/OR FOOD ESTABLISHMENTS, HOUSING <br />CONTRACTOR AND/OR PUBLIC POOLS, WATER SAMPLING Make <br />BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br />Jr.ENSE AND/OR POULTRY RANCHES AND KENNELS <br />3TRATION MISCELLANEOUS SERVICES Regist. No. <br />1,.BER Color <br />[Application Date zjo - Business/Name To Appear On Permit <br />oType Permit/Servir Requested:— <br />I- <br />z i <br />Applicantl­­ Address 2_ COLEY <br />2 Business Telephone No. Emergency Telephone No. <br />a2 Property Location/ dress Aflqg� <br />d Property Owner Address <br />-L Operator's Name Address <br />1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br />0 RESTAURANT El FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE 0 MEAT MARKET <br />0 FOOD PROCESSING PLANT 11 COMMISSARY 11 ICE PLANT 11 BAKERY <br />11 ROADSIDE FOOD STAND 0 LIQUOR STORE 11 BAR 0 ITINERANT RESTAURANT <br />0 CONFECTIONARY STORE ❑ FOOD SALVAGER 13 FOOD DEMONSTRATION 0 FOOD VENDOR <br />❑ VENDING MACHINES/No. of 0 MOBILE FOOD PREP. UNIT 13 VENDING VEHICLE <br />❑ FOOD CROP HARVESTING/No. of Field Employees <br />ALL APPLICANTS: Total Employees Including Operators <br />2. HOUSING <br />0 HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br />0 MOBILE HOME PARK/No. of Spaces <br />3. WATER QUALITY 0 WATER SAMPLE (Bacterial) ❑ CHEMICAL <br />1:1 PUBLIC WATER SYSTEM 11 SURFACE WATER SUPPLY 0 WATER HAULER <br />NO. OF PUBLIC SERVED (Connections) <br />4. RECREATIONAL HEALTH 11 SWIMMING POOL 0 SPA 11 WADING POOL 0 NATURAL BATHING PLACE <br />5. VECTOR CONTROL 0 POULTRY FARM/Maximum No. of Birds <br />r :ENNEL/Runways — /Animal Population No. No. of Confining Cages <br />Sewage Disposal Method <br />Solid Waste DiSDosal Method <br />Water Supply Source Animal Waste Disposal Method <br />6. El CONSULTATION FEE <br />7.VAPLAN CHECKING FEE <br />F <br />8. L ESTATE <br />REQUEST: Water Well Inspection 0 SampleO Title Company <br />Sewage System Inspection 0 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 ate that I prepared this application and that the work will be done in accordance with San Joaquin County <br />,A w <br />ordinances, s la n rutes and regulations of the San Joaquin Local Health D* <br />APPLICANT'S SIGNATURE X Title <br />—Date <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUAI 1❑ PER UNIT ❑ PER SITE 1:1 EACH 0 January 1 & Received By January 31 ❑ July 1 & Received By July 31 <br />BASE <br />EXPLANATION <br />BILLING <br />REMITTANCE <br />$ <br />AMOUNT <br />REMIT <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEE <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />#1. <br />Rec by D Receipt No. Permit No. Ance Date Mailed Delivered <br />