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> Applications Will Be Prod When Submitted Properly Completed. Be So Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> vAPP NEARS AND,OH N; RIC IN �GI <br /> APP'NEERICANS AND/OR FODU ESTABLISHMENTS.MOUSING If <br /> CP FACTOR AND/OR PUBLIC POOLS, WATER SAMPLING <br /> R AND/OR REAL ESTATE INSPECTIONS Lic <br /> SE AND/OR POULTRY RANCHES AND KENNELS Regisl. No. - <br /> >I RATION MISCELLANEOUS SERVICES <br /> I. . QOldf <br /> dEN -._ - <br /> < c' <br /> Application Date �-�I 2 I I d j. . ._. Business/Marne To Appear On Permit � \ <br /> in Type Permit/Service Requested ITLGiLI (L 1..^�, LL) <br /> a Applicant Name 1 I-c `� f _<'< .i.t 1 - Address ! , -' , , Clc �1. �.0 r'l� ..s. .� !✓}i( <br /> ' 4 <br /> L C- .J ::11 '�.- 1C TI 2CL` 7. Business Telephone No _. - Emergency Telephone No <br /> ,Property Location/Address <br /> -1Property Owner _ - __-__ __ - - Address <br /> a <br /> -1 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 /> ECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> ECTOR CONTROL ❑ POULTRY FARM/Maximum No of Birds . _... <br /> .ENNEL/Runways _ /Animal Population No. __ __ No.of Confining Cages <br /> Sewage Disposal Method _.- <br /> Solid Waste Disposal Method <br /> Water Supply Source .___ ____ _-_ -_- Animal Waste Disposal Method <br /> 6. CONSULTATION FEE --.- --Lb � �`----- ------- ---- ---- <br /> 7. ❑ PLAN CHECKING FEE - <br /> 8. 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_ -.—.___._-- - --_-. Dale._FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 A Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE E AMOUNT DUE- CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 5s to NZ S u'ice. <br /> LESS _ <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> orHe" Tf. 5,) <br /> OTHER <br /> Heccivuu ny Date Feceipt No Permit IN Issuance at Matle❑ Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E HAZEL AvF P.o.Ra.laov STOCN 111.1 G.1,I _ <br />