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Applications Will Be-Processed When Submitted Properly Completed. R -lure To Sign The Application. <br /> APPLICATION ' <br /> NVIRONMENTAL HEALTH PERMIT/SERVICES <br /> tNc;Nt FR'S AND OR IF VEHICLE INVOLVED,GIVE <br /> A PPL[CANT ANDrUR O FOOD ESTABLISHMENTS.HOUSING Make - <br /> CONTRACTOR ANDrOR PUBLIC POOLS.WATER SAMPLING <br /> RROKER AND OR / t REAL ESTATE INSPECTIONS Lic. NO. <br /> ,r'.FNSE AND OR f \i POULTRY RANCHES AND KENNELS Regist. No. <br /> irRATION <br /> MISCELLANEOUS SERVICES - <br /> i OFR <br /> Application Date .r - Business/Name yo Appear n Permit . .; 1 <br /> Type Permit Service,je u Ste{i: - <br /> z /- / /� Address <br /> a Ap�lican Name _ - - - -- - - <br /> usiness 7p <br /> 1, <br /> \ No.?/ .-� / =� Emergency Telephone No. <br /> a .� <br /> a Property Location/Address - <br /> Property Owner �� � t��CA_VeVj_C,E - - - Address --- -- ---- ---- <br /> a - <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 QUALITY ❑ 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 /> Solid Waste Disposal Method - <br /> Water Supply Source nlmal Waste-Disposal Melthod <br /> 6. J9; CONSULTATION FEE �G=_L L ��1_�LCr�7 - <br /> 7. ❑ PLAN CHECKING FEE -- — <br /> &. 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 Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July I &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> --- ._...- ----- -- ..- ----- -------- - — AMOUNT <br /> — <br /> FFE <br /> LESS <br /> PRORA7 ION <br /> PLUS <br /> PE NAL1 Y <br /> OT FIER <br /> OTHER <br /> 11 <br /> 1-ryf��'ll by nattn- Receipt No v - Permit No Issuance Date Mailed Delivered <br /> / n--. -• - • -ter\. rk"'•nnNUFPtTAI NF'1I.TH I--iii-gFnvlr- 1- r .f n - -..n1 <br /> n-rnVTn.. ..- rr17/� _.--_ <br />