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ENGINEER'S AND/OR <br />APPLICANT'S AND/OR <br />CONTRACTOR AND/OR <br />BROKER AND/OR <br />LICENSE AND/OR <br />REGISTRATION <br />NUMBER <br />Applications Will Be Processed When Submitted Properly Completed.ure To Sign The Application. <br />APPLICATION Is <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES GENERAL <br />FOOD ESTABLISHMENTS, HOUSING <br />PUBLIC POOLS, WATER SAMPLING <br />REAL ESTATE INSPECTIONS <br />POULTRY RANCHES AND KENNELS <br />MISCELLANEOUS SERVICES <br />.Application Date Business/Name To Appear On Permit F <br />IF VEHICLE INVOLVED, GIVE <br />Make <br />Lic. No. <br />Regist. No. <br />Color <br />Type Permit/Service Requested: <br />`Applicant Name Frank Miller. Inc. Address IBM JEW110. RIVW <br />Business Telephone No. Emergency Telephone No. <br />.Property Location/Address 1_M6 E. *11A Own <br />aProperty Owner Address <br />1 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 POULTRY FARM/Maximum No. of Birds 170,000 <br />❑ KENNEL/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 ❑ BUSINESS LICENSE <br />7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br />8. 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 <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 REMITTANCE <br />$ <br />AMOUNT DUE <br />CHECKED <br />DATE DATE <br />REMITTED <br />FEE <br />�y� <br />$100.00 <br />,��y <br />1984 <br />/1 piC 1.- ,� i <br />ry�y h� <br />$1W.00 <br />yAMOUNT <br />X <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />Received by Oatb& Receipt No. Permit No. Issuance Date Mailed Delivered <br />............� ..v.. ..... .... nwn.��. tn. vu.n.nuue.Tw, ueu to .....rice Dv. P.CC 1— a YA7C1 TnM eve D n D.... 9 M CTnr`IrTew CA D59M <br />