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Applications Will Be ProcesSP4 When Submitted Properly Completed. Be Sure To Sign The Application. <br />APPLICATION <br />E14 RONMENTAL HEALTH PERMIT/SERVIC01 GENERAL <br />ENGINEER'S AND/OR QUESTIONS CALL 460-6781, EXt. 34 IF VEHICLE INVOLVED, GIVE <br />APPLICANT'S AND/OR FOOD ESTABLISHMENTS, HOUSING Make <br />CONTRACTOR AND/OR PUBLIC POOLS, WATER SAMPLING <br />BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br />LICENSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br />REGISTRATION MISCELLANEOUS SERVICES <br />NUMBER IS E WITH APPLICATION BEFORE DUE DATE AS SHOWN BELOW' - <br />[Application Date 11/1/82 Business/Name To Appear On Permit Frank Miller, Inc. <br />,n Type Permit/Service Requested: <br />a Applicant Name Frank Mi 11 e r , . Inc. Address 18800 E. Mello, R i pon 95366 <br />Business Telephone No. Emergency Telephone No. <br />a Property Location/Address 18800 E Me i l o Rd., Ripon <br />a Property 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 />4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br />5. VECTOR CONTROL C1 POULTRY FARM/Maximum No. of Birds 170,000 <br />❑ KENNEL/Runways <br />Sewage Disposal Method <br />Solid Waste Disposal Method <br />Water Supply Source <br />6. ❑ CONSULTATION FEE <br />7. ❑ PLAN CHECKING FEE <br />8. REAL ESTATE <br />/Animal Population No. <br />REQUEST: Water Well Inspection Sample El <br />Sewage System Inspection ❑ <br />Escrow No. <br />Seller <br />Telephone No. <br />Service Request For Date <br />No. of Confining Cages <br />Animal Waste Disposal <br />❑ BUSINESS LICENSE <br />❑ DANCE PERMIT <br />Title Company <br />Address <br />Seller Address <br />Seller Agent Name _ <br />ENVIROMENTAL HEALTH <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 SIGNATU�' X <br />Title <br />Date <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: `R ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH R1 January 1 & Received By January 31 ❑ July 1 & Received By July 31 <br />REMIT <br />BASE EXPLANATION <br />BILLING <br />REMITTANCE $ <br />AMOUNT DUE <br />CHECKED <br />DATE <br />DATE REMITTED <br />AMOUNT <br />FEE <br />$100.00 1982 <br />1/1/82 <br />due 1/31/82 <br />$100.00 <br />X <br />LESS <br />PRORATION <br />PENALTY <br />PENALTIES WIILL BE ADDED <br />AFTER DUE D <br />TE SHOWN2EI OW <br />OTHER <br />30 DAYS - 0°Jo of BASE FEE <br />OTHER <br />90 DAYS -,5% of BASE FEE <br />Received by Datel Receipt No. Permit No. Issuance Date Mailed Delivered <br />---• •---•— ---.._..... ___.__ _.._ _.....�......�..�...,�.. �., ..c.....�.ece.....cc .ew, c .,.mac. rnu .vc e n n.... �nno crnrrrnu cA oa�m <br />