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Applications Will Be Pre—assed When Submitted Properly Completed. Be S. To Sign The Application. <br /> • APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING Make <br /> BROKER AND.IOR REAL ESTATE INSPECTIONS Lic. No. <br /> Ir'ENSE AND.OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICIES Regist. No.-----_ <br /> I. .BER -­­ ----- -a(� Color -- <br /> Application Date 1 v=/ Business/Name To Appear On Permit <br /> P-Type Permit/Service Req�ule�sted: <br /> uApplicant Name _-_ �-(�GN�]" l YtSe _' 2SOC__ _ _ Address <br /> 62 _ Bu mess Telephone No.--_ -__ Emergency Telephone No. — <br /> a Property Location/A dress <br /> aProperty Owner-- G -- - - -- -- - Address ------- — <br /> L Operator's Name -- SJ 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 ❑ 1„101LIOR STORE [I GAR ❑ 11 INERANT 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 - Animal Was a Disposal Method _ <br /> 6. 93CONSULTATION FEE ) �l�I •LOYI) � �— <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 /> - ------- ---- <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 1 8 Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> —DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION PrNk <br /> Il I RF <br /> 1 I� <br /> PLUS PENALTY DAYS FROM BIWNG DATE. <br /> ,,! <br /> OTHER r�1 bJ`L In I r O 4/12/89 _ <br /> OTHER <br /> Received by j% Date neceipt No. rermt No Issuance Date Mailed Delivered <br /> APPLICANT�—_AETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT,SERVICES 1601 E.HA?ft TnN 4XF 4.n 9a•MW %Tnr'MTAA+ r•a.,an+ <br />