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Applications Will Be Processed When Submitted Properly Completed. Be Sure I o Sign The Application. APPLICATION FVOLYVGIVE ENGINEER'S ANC/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES CANT S AND OR F000 ESTABLISHMENTS.HOUSING IF 'ACTOR AND/OH PUBLIC POOLS.WATER SAMPLING ke I I AND,,OR REAL ESTATE INSPECTIONS Lic. No. -1 AND,-OH POULTRY RANCHES AND KENNELS 3THArION MISCELLANEOUS SERVICES Reglst. No. a. i1EH - /, Color - -- ---- iApplication Date -,4-,(o-89_ _______.._.. Business/Name To Appear On Permit ,a Type Permit/Service Requested: ._ Applicant Name Address �Q3 Z . ( 1J-E -- -- U N-- 2 -. Bu mess Telephone No. ._ _ _ _ Emergency Telephone No. a Property Location/Agdress� f�/f�1f1l.�_ 'F 7"-fly - -- <Property Owner Address _. - (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/MOTEL/No. of Units _____ ❑ CERTIFICATE OF OCCUPANCY ❑ MOBILE HOME PARK/No. of Spaces _- 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER NO, OF PUBLIC SERVED (Connections)--_- _- 4&REATIONAL HEALTH ❑ SWIMMING POOL 1:1 SPA 11 WADING POOL ❑ NATURAL BATHING PLACE 5. TOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds _.._ ------------ r :ENNEL/Runways - ---- /Animal/Animal Population No. No. of Confining Cages--- Sewage Disposal Method - .. ___-- Solid Waste Disposal Method ------------- ------ ------------------------- Water Supply Source Animal Was a Disposal MethodI _ 6. CONSULTATION FEE -- =_� ---1 — ---- 7. PLAN CHECKING FEE B. REAL ESTATE REQUEST. Water Well Inspection 13 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 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 '-'------------- -------- BREMITTANCE $ REMIT BILLING BASE EXPLANATION AMOUNT OUE CHECKED DATE DATE REMITTED AMOUNT FEE i --- ------ --- ir AUS PENALTY tr OTHER-- � 4/12/89 OTHEH Received by Date Receipt No reinna No - Issuance Dale --- Maded DVhvprep _ -