Laserfiche WebLink
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. Be Sure To Sign The Application. <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES CENERAL <br />FOOD ESTABLISHMENTS, HOUSING <br />PUBLIC POOLS. WATER SAMPLING <br />REAL ESTATE INSPECTIONS <br />POULTRY RANCHES AND KENNELS <br />MISCELLANEOUS SERVICES <br />IF VEHICLE INVOLVED, GIVE <br />Make <br />Lic. No. — <br />Regist. No. <br />Color <br />FApplication Date 10 30/79 _. Business/Name To Appear On Permit <br />,Type Permit/Service Requested: - -- <br />a Applicant Name Hoak Well dr Eqlai nalrnT. Address 189.5 Tosemi t Tn vd I Modesto <br />U <br />Business Telephone No. Emergency Telephone No. <br />aProperty Location Address 7�o <br />aProperty 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 <br />❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE <br />❑ CONFECTIONARY STORE <br />❑ VENDING MACHINES/No, of <br />❑ FOOD CROP HARVESTING/No. of Field Employees _ <br />ALL APPLICANTS: Total Employees Including Operators <br />❑ FOOD SALVAGER <br />❑ ICE PLANT ❑ BAKERY <br />❑ BAR ❑ ITINERANT RESTAURANT <br />❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br />❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br />2. HOUSING <br />❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br />❑ MOBILE HOME PARK/No. of Spaces <br />3. WATER QUALITY EX 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. <br />VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <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 />/Animal Population No. <br />No. of Confining Cages <br />Animal Waste Disposal Method <br />❑ BUSINESS LICENSE <br />❑ DANCE PERMIT_ <br />8. REAL ESTATE <br />REQUEST: Water Well Inspection 11 Sample[] Title Company <br />Sewage System Inspection ❑ Address <br />Escrow No. <br />Seller <br />Telephone No. <br />Service Request For Date <br />Seller Address <br />Seller Agent Name <br />Tele. No. <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 EqJEACH ❑ January 1 & Received By January 31 ❑ July 1 & Received By July :i'. <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.OD <br />Qhg, <br />10/30%79 <br />$38.00 <br />_ <br />LESS <br />PRORATION. <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />Received by D to Receipt No. Permit No. Issuance Date Mailed Delivered <br />........... ru.cnu.r,nc.mrcn 1.1 uevcr muev. on n.. rano arncernune nssnl <br />