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Applications Will Behr en Submitted Properly Completed. Be Sure To Sign The Application. <br />�jv( APPLICATION GENERAL <br />VI MENTAL HEALTH PERMIT/SERVICES <br />E <br />ENGINEER'S AND/ORAPPLICANT'S <br />o <br />AND/OR <br />CONTRACTOR AND/OR <br />241989 <br />TABLISHMENTS. HOUSING <br />PUBLIC ICPOOLS, WATER SAMPLING <br />BROKER AND/OR <br />SAN <br />REAL ESTATE INSPECTIONS <br />LICENSE AND/OR <br />KENNELS <br />REGISTRATION <br />NUMBER <br />' 1 T�'" <br />wAAI .�' <br />MISCELLANEOUS SERVICES <br />$ <br />Is-vplc1 <br />NEp,�.TN u1S <br />CHECKED <br />IF VEHICLE INVOLVED, GIV <br />Make <br />Lic. No. <br />Regist. No. <br />Color <br />FApplication Date Business/Name To Appear On Permit Par Cou^try Estates <br />oType Permit/Service Requested: - - - <br />�ApplicantName Howk Well & Equipment Co. Address 1825 Yosemite Blvd., Modesto <br />j Business Telephone No. Emergency Telephone No. <br />a Property Location/Address Chrisman Rd. <br />a <br />Property Owner Address <br />L Operator's Name Address <br />1. <br />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 <br />ROADSIDE FOOD STAND ❑ LIQUOR STORE <br />❑ CONFECTIONARY STORE ❑ FOOD SALVAGER <br />❑ VENDING MACHINES/No. of <br />❑ FOOD CROP HARVESTING/No. of Field Employees <br />ALL APPLICANTS: Total Employees Including Operators <br />2. HOUSING <br />❑ BAR <br />❑ FOOD DEMONSTRATION <br />❑ MOBILE FOOD PREP. UNIT <br />❑ BAKERY <br />❑ ITINERANT RESTAURANT <br />❑ FOOD VENDOR <br />❑ VENDING VEHICLE <br />❑ HOTEUMOTEUNo. 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 />A. RECREATIONAL HEALTH ❑ SWIMMING POOL <br />❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br />S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br />❑ KENNEURunways /Animal Population No. <br />Sewage Disposal Method <br />Solid Waste Disposal Method <br />Water Supply Source <br />6. ❑ CONSULTATION FEE <br />7. ❑ PLAN CHECKING FEE <br />S. REAL ESTATE <br />REQUEST: Water Well Inspection Sample❑ <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 Method <br />❑ BUSINESS LICENSE <br />❑ DANCE PERMIT <br />Title Company <br />Address - Tele. No. <br />_ Seller Address <br />Seller Agent Name <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 />APPLICANTS SIGNATURE <br />Title <br />Date <br />FOR DEPARTMENT: USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 a 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 />$38.00 <br />11/19/79 <br />1/3/80 <br />$38.00 <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />n <br />Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered <br />.00„r..,.—ecr„ou e„ rn¢me rn. cuvi¢nuueure, ueei Tu ¢c¢wrmc¢mrce gym. a uum mu ew o n ¢... Dona ¢mrcrnu ee ¢som <br />