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lik Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. POULTRY RANCHES AND KENNELS MISCELLANEOUS SERVICES rApplication Date Business/Name To Appear On Permit ,*Type Permit/Service Requested: i Applicant Name _ _ — __ Address v IL ___ - __ Business Telephone No. Emergency Telephone No. Property Location/Address _ iProperty Owner __ _ _ _ __ __ Address I Operator's Name _ 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/!HOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY ❑ MOBILE HOME PARK/No. of Spaces 3. WATER DUALITY ❑ 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 ❑ KENNEL/Runways /Animal Population No. _ No. of Confining Cages Sewage Disposal Method Solid Waste Disposal Method Water Supply Source Animal Waste Disposal Method S. ❑ CONSULTATION FEE BUSINESS LICENSE 7. ❑ PLAN CHECKING FEE _ _ _ _ ❑ DANCE PERMIT 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. APPLICANT'S SIGNATURE X _ _ Title Date SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL ENGINEER'S AND/OR APPLICANT'S AND/OR CONTRACTOR AND/OR APPLICATION ENVIRONMENTAL HEALTH PERMIT/SERVICES IF VEHICLE INVOLVED, GIVE Make BROKER AND/OR Lic. No. LICENSE AND/OR REGISTRATION FOOD ESTABLISHMENTS, HOUSING PUBLIC POOLS, WATER SAMPLING Regist. No. NUMBER _ REAL ESTATE INSPECTIONS Color POULTRY RANCHES AND KENNELS MISCELLANEOUS SERVICES rApplication Date Business/Name To Appear On Permit ,*Type Permit/Service Requested: i Applicant Name _ _ — __ Address v IL ___ - __ Business Telephone No. Emergency Telephone No. Property Location/Address _ iProperty Owner __ _ _ _ __ __ Address I Operator's Name _ 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/!HOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY ❑ MOBILE HOME PARK/No. of Spaces 3. WATER DUALITY ❑ 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 ❑ KENNEL/Runways /Animal Population No. _ No. of Confining Cages Sewage Disposal Method Solid Waste Disposal Method Water Supply Source Animal Waste Disposal Method S. ❑ CONSULTATION FEE BUSINESS LICENSE 7. ❑ PLAN CHECKING FEE _ _ _ _ ❑ DANCE PERMIT 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. APPLICANT'S SIGNATURE X _ _ Title Date a 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' E AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered l`r110IFC Tn FNVIRr1NYFNTAI HFAI TN PFRU1T/1FRVIr'F1 1An1 F HAM TnN AVF P Rn• ?nn9 9Tnr:KTnN r:A 9571711 a