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APPLICATION ENGINEER'S AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES APPLICANT'S AND/OR CONTRACTOR AND/OR FOOD ESTABLISHMENTS,HOUSING IF VEHICLE INVOLVED,GIVE BROKER AND/OR PUBLIC POOLS WATER SAMPLING Make ir'ENSE AND/OR REAL ESTATE INSPECTIONS 3TRATION POULTRY RANCHES AND KENNELS Lie. No. I. .AER MISCELLANEOUS SERVICES Regist. No.. Color Application Date Business/N me To A i Type Permit/Service Requested: pPear On Permit oApplicant Name`z —� Address `---- Busin Telephone No. - 7 .._ 4 Property location/Address o --- -- mergency ephone No. i Property Owner, DL.LS p i -)Operator's Name Address I. FOOD ESTABLISHMENTS Address Total Building Sq. Footage Restaurant, Maximum Seating Capacity ❑ RESTAURANT E FOOD MARKET-RETAIL E3 FOOD MARKET WHOLESALE ❑ MEAT MARKET ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ROADSIDE FOOD STAND ❑ ❑ ICE PLANT ❑ BAKERY STORE 13❑ CONFECTIONARY STORE ❑ FOOD SAL AGER 13 FOOD El ITINERANT RESTAURANT ❑ VENDING MACHINES/No. of FOOD DEMONSTRATION ❑ FOOD VENDOR ❑ FOOD CROP HARVESTING/No.of Field Employees ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE ALL APPLICANTS: Total Employees Including Operators 2. HOUSING ❑ HOTEL/MOTEL/No. of Units ❑ MOBILE HOME PARK/No.of Spaces ❑ CERTIFICATE OF OCCUPANCY 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ NO. OF PUBLIC SERVED (Connections) WATER HAULER 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ 5. VECTOR CONTROL ❑ WADING POOL 11 NATURAL BATHING PLACE POULTRY FARM/Maximum No.of Birds r :ENNEL/Runways ___ /Animal Population No. Sewage Disposal Method �— No.of Confining Cages Solid Waste Disposal Method Water Supply Source B. ❑ CDNSULTATIQN FEE Animal Waste Disposal Method /' 7. PLAN CHECKING FEE 8. REAL ESTATE REQUEST: Water Well Inspection❑ Sample[] Title Company Sewage System Inspection ❑ Address Escrow No. -_ _ Tele. No. Seller Seller Address Telephone No._ Seller Agent Name Service Request For Dat ----- - I hereby certify that e r ed th' applica and that the work will be done in accordance with San Joaquin County ordinances, state la s• n ruI an ulations of San Joaquin Local Health District. APPLICANT'S SIGNATURE X �f�� Title < Date ) 2 $S'S FOR DE RTMENT USE ONLY Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Receivee By January 31 ❑ July 1 A Rmeived By July 31 BASE EXPLANATION BILLING REMITTANCE S REMIT -- DATE DATE REMITTED AMOUNT DUE CHECKED FEE / AMOUNT LESS 7v U --.. PRORATION PLUS PENALTY OTHER OTHER e,ved by Dale Receipt No. P Permit No Issuance Dale APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ,u.a _.��.��.. .... __MuleE Oehve.etl .