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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. Be Sure To Sign The Application. <br />APPLICATION <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 />IF VEHICLE INVOLVED, GIVE <br />Make <br />Lic. No. <br />Regist. No. <br />Color <br />FApplication Date, ,---? _— Business/Name To Appear On Permit _ <br />FType Permit/Service Requested - <br />`Applicant Name Address <br />n <br />Business Telephone No, Emergency Telephone No. <br />a Property Location/Address _ _. __ — _ � %`� zi <br />aPropertyOwner - _ 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 />❑ ICE PLANT ❑ BAKERY <br />❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE <br />❑ BAR ❑ ITINERANT RESTAURANT <br />❑ CONFECTIONARY STORE ❑ FOOD SALVAGER <br />❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br />❑ VENDING MACHINES/No. of <br />❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br />❑ FOOD CROP HARVESTING/No. of Field Employees <br />ALL APPLICANTS: Total Employees Including Operators <br />EXPLANATION <br />2. HOUSING <br />REMITTANCE <br />❑ HOTEL/MOTEL/No. of Units <br />❑ CERTIFICATE OF OCCUPANCY <br />❑ MOBILE HOME PARK/No. of Spaces <br />3. WATER QUALITY A WATER SAMPLE (Bact r 1) ❑ CHEMICAL <br />❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY <br />❑ WATER HAULER <br />NO. OF PUBLIC SERVED (Connections) <br />REMITTED <br />4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA <br />❑ WADING POOL ❑ NATURAL BATHING PLACE <br />5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br />❑ KENNEL/Runways /Animal Population No. <br />No. of Confining Cages <br />Q--. nicnnc.l nnethnrl <br />Snlid Wacta Disnnsal Method _ <br />Water Supply Source Animal Waste Disposal Method <br />S. ❑ 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 />Date <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE Cl EACH ❑ January 1 & Received By January 31 ❑ July 1 & 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 />7,, <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />^/ <br />Received by D le Receipt No. Permit No. Issuance Date Mailed Delivered <br />..........— ...................—.... ...,.e........... —.....—....--.— .... a u.—m., Ao_.— arnrr.nu n. a.sm <br />