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Applications WIII Be Pro 10 <br /> d When Submitted Properly Completed. Be Su* Sign The Application. <br /> APPLICATION <br /> �e ENVIRONMENTAL HEALTH PERMIT/SERVICES IF VEHICLE INVOLVED, GIVE <br /> ENGINEER'S AND:OR FOOD ESTABLISHMENTS.MOUSING Make <br /> APPLICANT'S ANDrOR PUBLIC POOLS.WATER SAMPLING <br /> CONTRACTOR AND/OR REAL ESTATE INSPECTIONS LIC. No. --- - <br /> NROKER AND/OR POULTRY RANCHES AND KENNELS Reg ist. NO.—. <br /> irRNSE AND/OR MISCELLANEOUS SERVICES <br /> STRATION Color _--- <br /> i. .aER - - - - <br /> Application Date —__------ <br /> __ Business/Name To Appear On Permit _ - -- --- - -- - - <br /> F Type Permit/Service Requested.— <br /> sApplicant Name —$tktOp--S@Y' ]�2--$t3t1-Of�-EQT <br /> UD Address <br /> OC ---- <br /> g _ Business Telephone No.--- .. Emergency Telephone No. — <br /> a _ <br /> 'a Property Location/Address <br /> _--- Address --_._-- ---- ----_ - -._-- <br /> aProperty Owner _. -- ---------- - --__ <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 /> ElHOTEL/MOTEL/No. of Units 11 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 /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> r :ENNEL/Runways - -.--- /Animal Population No. _—. No. of Confining Cages <br /> Sewage Disposal Method - <br /> Solid Waste Disposal Method <br /> - -. Animal Waste Disposal Method <br /> Water Supply Source <br /> 6. CONSULTATION FEE PiPi <br /> - <br /> 7. ❑ PLAN CHECKING FEE <br /> B. REAL ESTATE <br /> REQUEST. Water Well Inspection 13 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 X .— Title-- - Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 6 Received By January 31 ❑ July 1 d ReceiveddEMIT By July 3I <br /> BASE EXPLANATION BILLING REMITTANCE E AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> EEE_— $35.00 1/18/89 <br /> LESS <br /> PRORATION <br /> PLUS $ 3.50 Penalty 4/3./89-- $38.50 <br /> PENALTY _ --- <br /> OTHER <br /> OTHER _ -- <br /> L eceivW by Date Rece,pl No. Perms No Issuance Dale Mailed Da ivered n <br /> e,, mulls Tn'- _-•"'^"••"'Z" =`1UTB oIEfl1N cpmrcC ram c ubcrnu•oc en e...anro emrr rnu r.o<o <br />