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i i ENGINEER'S AND�OR APPLICANT'S AND/OR CONTRACTOR AND OR BROKER AND,OR rFNSE AND/OR 3TRATION BER ___- Applications Will Be F !d When Submitted Properly Completed. Be : , Sign The Application. -- APPLICATION ENVIRONMENTAL HEALTH PERMIT/SERVICES FOOD ESTABLISHMENTS, HOUSING PUBLIC POOLS. WATER SAMPLING REAL ESTATE INSPECTIONS POULTRY RANCHES AND KENNELS MISCELLANEOUS SERVICES IF VEHICLE INVOLVED, GIVE Make . -- Lic. No. - Regist. Nq. Color _ Application Date _ �� 2L—.. Business/Name To Appear On Permit_— [Type Permit/ServiceeqF L- _._�'.dl'--i_Lrt r -. l "P" =Applicant Name �_�.___ ___ Address -351- Business Telephone No. .l �./ Emergency Telephone No. ' gProperty Location/Address,,41. x_. 12-s._1K 21r�.'..�_— <Property Owner __�Cf��7 P //�-s�_`"_[S,C.4_ ,�� - _ Address (Operator's Name _-_ Address ---- __._ 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER E3 FOOD DEMONSTRATION ❑ FOOD VENDOR ❑ VENDING MACHINES/No. of - ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE ' ❑ FOOD CROP HARVESTING/No. of Field Employees ALL APPLICANTS: Total Employees including Operators 2. HOUSING ❑ HOTEL/MOTEL/No. 01 Units __�___-._ ❑CERTIFICATE OF OCCTli(,�n' L/ Ind ❑ MOBILE HOME PARK/No. of Spaces 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL 01 1989 ❑ PUBLIC WATER SYSTEM 13 SURFACE WATER SUPPLY ❑ WATER HAULER NO. OF PUBLIC SERVED (Connections) — _ __ ENVIRONFAIENTAL HEALTH 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHMM/ dikVICES S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds F :ENNEL/Runways _ — /Animal Population No. _ __ No. of Confining Cages Sewage Disposal Method—__._____ Solid Waste Disposal Method Water Supply Source Animal Waste Disposal Method B. 00 ,C;+o►1SULTATION FEE 7. Ucr N CHECKING FEE •S O i f h 6 r jn r__�S _. ,.p F' Yn (u V" r✓ i !t v'�}/u L a. REAL ESTATE REQUEST: Water Well Inspection❑ Sample❑ Title Company Sewage System Inspection ❑ Address _ Tele. No. Escrow No, Seller ____._______.___ ____ Seller Address Telephone No. .__-_____.. Seller Agent Name Service Request For Date I hereby certify that I have prepared this application and that the work will be done in accordance With San Joaquin. County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District, APPLICANT'S SIGNATURE X -------- ----._ Title - - Date FOR DEPARTMENT USE ONLY Fee Is Duo: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Receivetl By January, 31 ❑ July 1 6 Received ey JWy 31 REMIT EASE EXPLANATION BILLING REMITTANCE R It AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE 3 LESS PRORATION-------- PLUS PENALTY OTHER '�-—•----- �— Pi _---- - -- OTHEM ---- - --- - — ------ -# o RecelYad by Dale Receipt No Permu No n {Quu anta DAIa Flaoso Dallwra6 ...... ....... ......... ... ......vc .... ..,..,u......v..... ...................ui.... .d.. —4;......,... .n .._— ..nn,r.nu 1...er,. _—