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Applications Will Be PrWhen Submitted Properly Completed. Be S ign The Application. <br />40 APPLICATION <br />A ,I ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />ENGINEER'S AND/OR <br />APPLICANT'S AND/OR <br />CONTRACTOR AND/OR <br />BROKER AND/OR <br />Ir1ENSE AND/OR <br />3TRATION <br />BER <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 />Regisl. No. <br />Color <br />f Application Date � � Business/Name To Appear On Permit <br />,Type Permit/Service Reques.14101 <br /><Applicant Name <br />u Business Telephone No.. �g�� Emergency Telephone o. <br />J <br />1 Property Location/Address <br />aProperty 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 OUALITY ❑ 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 />ounu vvau,c Vvao mm,,.... - <br />Water 5 ly Source _ Animal Waste Disposal Method <br />8. CONSULTATION FEE <br />T. u .PLAN GneVnmu roc <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 />lnAAIT'C Cir -MATT IRF X <br />Title <br />Date <br />APPLICANT—RETURN ALL COPIES TO: ElINTRONMENTAL HEALTH PERMIT/SERVIGEa <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY <br />❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 <br />A Received By January 31 <br />July 1 8 Received By July 31 <br />REMIT <br />BASE <br />EXPLANATION <br />BILLING REMITTANCE <br />DATE <br />E <br />REMITTED <br />MOUNT UE CHECKED <br />AMOUNT <br />FEE <br />4DATE <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />— <br />OTHER <br />`� <br />✓�� <br />�� <br />OTHERS <br />Received by <br />a <br />�� <br />re�celpt No. <br />Permit No <br />IS:;;ance Date <br />Mailed Delivered <br />APPLICANT—RETURN ALL COPIES TO: ElINTRONMENTAL HEALTH PERMIT/SERVIGEa <br />