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Applications rill Be Pro( 'd When Submitted Properly Completed- Be Sur Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND,OR IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS. HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING - -- <br /> BROKER AND/OR REAL ESTATE INSPECTIONS LIC. No. — <br /> IrENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No, _- <br /> 1, dER Colo! <br /> Application Date . LL'2_�S% Business/Name To Appear On Permit <br /> Type Permit/Servic Requested: <br /> DWKD� <br /> Addr s <br /> wtYJQ_ Business elephon o.��� q3--�i��_ Emergency Telephone No. <br /> roperty Location/Addres <br /> iProperty Wner - _ ��_.. .—. 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 /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. 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 /> Water Supply Source _ An,'{ma-l_W-aste Disposal Method <br /> 6. 11 <br /> CONSULTATION FEE �LUIC.FS <br /> 7. PLAN CHECKING FEE <br /> B. 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 X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 d Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> - _. AMOUNT <br /> FEE � al <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER --- <br /> -_ _ T <br /> OTHER_ -_�.__ _ ..___ _—_ _ _ •I ___ <br /> deceived by We Receipt No Permit No Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E-HAZFLTON AVE. P Rn.anon Smcr TnR rA"101- <br />