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r 0 ENGINEER'S AND/OR APPLICANT'S AND/OR CONTRACTOR AND/OR BROKER AND/OR irENSEAND/OR 3TRATION dER Applications Will Be ceased When Submitted Properly Completed. Be •e To Sign The Application. APPLICATION ENVIRONMENTAL HEALTH PERMIT/SERVICES Application Date 7 ZZ Business/Name To Appear On Permit E% --s rnType Permit/Service Requested: <Applicant Name i:r)e"t W�� t— Add ss 8D 2Z .Z NiPiCc' 9S3 yC� U BusiinJss Telephone No�q. 6753 -Y –/D y/ Emergency Telephone No.��cg X06%_S3 ys IL Property Location/Address —I 221 E. 78's I e- Xe , Mg n E ca q.5 3-3 6 a Property Owner V Mv6re--Address Pa Box (.7 a4n , q'`3ay [Operator's Name 774 C 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 ❑ 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. of Units ❑ CERTIFICATE OF OCCUPANCY ❑ MOBILE HOME PARK/No. of Spaces 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER NO. OF PUBLIC SERVED (Connections) 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds .ENNEL/Runways /Animal Population No. No. of Confining Cages z>�wage Disposal Method Soliri Wactp nicnnsal Mpthnrl Water Supply Source Animal Waste Disposal Method 6. ❑ CONSULTATION FEE 7 ❑ PI AN r:HFr.KINr FFF _ M� 8. 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. n (' APPLICANT'S SIGNATURE X -+ Title Date FOR DEPARTMENT USE ONLY IF VEHICLE INVOLVED, GIVE FOOD ESTABLISHMENTS, HOUSING Make PUBLIC POOLS, WATER SAMPLING REAL ESTATE INSPECTIONS Lic. No. POULTRY RANCHES AND KENNELS Regist. No. MISCELLANEOUS SERVICES BASE EXPLANATION Color Application Date 7 ZZ Business/Name To Appear On Permit E% --s rnType Permit/Service Requested: <Applicant Name i:r)e"t W�� t— Add ss 8D 2Z .Z NiPiCc' 9S3 yC� U BusiinJss Telephone No�q. 6753 -Y –/D y/ Emergency Telephone No.��cg X06%_S3 ys IL Property Location/Address —I 221 E. 78's I e- Xe , Mg n E ca q.5 3-3 6 a Property Owner V Mv6re--Address Pa Box (.7 a4n , q'`3ay [Operator's Name 774 C 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 ❑ 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. of Units ❑ CERTIFICATE OF OCCUPANCY ❑ MOBILE HOME PARK/No. of Spaces 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER NO. OF PUBLIC SERVED (Connections) 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds .ENNEL/Runways /Animal Population No. No. of Confining Cages z>�wage Disposal Method Soliri Wactp nicnnsal Mpthnrl Water Supply Source Animal Waste Disposal Method 6. ❑ CONSULTATION FEE 7 ❑ PI AN r:HFr.KINr FFF _ M� 8. 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. n (' APPLICANT'S SIGNATURE X -+ Title Date FOR DEPARTMENT USE ONLY Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & Received By January 31 ❑ July 1 & Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE 3 LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No Issuance Date Mailed Delivered - '--"--"- ---.._..... ..,....�.. ..,.. �.............�..�.. ..�.. �.. ..�.....�,..�.,.....« ..n. ...— — ...e en n..., creno --nu re acorn