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' Applications Will Irocessed When Submitted Properly Completed Sure To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR I F V IC MVE GIVE <br /> APPLICANT'S AND/OR F000 ESTABLISHMENTS. HOUSING <br /> CONTRACTOR AND/OR PUBLIC POOLS, WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS <br /> .Ir'ENSE AND/OR POULTRY RANCHES AND KENNELS LI NO <br /> 3TRATION MISCELLANEOUS SERVICESB O <br /> il <br /> I. .aER Color <br /> [Application Date Business/Name To Appear On Permit <br /> e Type Permit/Service Requested: <br /> Applicant Name SEMCO Address 411 H_ Hath Rd. . Modacto <br /> u Business Telephone No. Emergency Telephone No. <br /> %Property Location/Address 4341 Hiffihard, StOCICton <br /> iProperty Owner Address <br /> 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 /> A. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> F :ENNEL/Runwaya /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 inS.peCtion Soil Sampling <br /> Y. ❑ PLAN CHECKING FEE <br /> S. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample 13 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 /> 1 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 X Title Da <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 I a Recsi,ediBy July 31 <br /> BILLING REMITTANCE $ MIT <br /> BASE EXPLANATION MO UE C CKED <br /> DATE DATE REMITTED UNT_ <br /> FEE $70 2 hrs @ 6/23/89 $ <br /> PRORATIONLESS <br /> r <br /> PLUS <br /> PENALTY <br /> OTHER Pf-N LTIES7 WILL B A"PLIEDTO PAST LDjUUE1 ,A11C COUMS 30 <br /> OTHER <br /> S O v 6 l� <br /> fleceived by Date Receipt No, Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISFRvmas wr a u..o.nu.... ... .__....... ...._.._�.. ___.__. <br />