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Applications Will Be P, :sed When Submitted Properly Completed. Be S o Sign The Application. APPLICATION ENVIRONMENTAL HEALTH PERMIT/SERVICES y- ENGINEER'S AND OR IF VEHICLE INVOLVED, GIVE APPLICANTS AND/OR FOOD ESTABLISHMENTS,HOUSING Make CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING ^•OKER AND/OR REAL ESTATE INSPECTIONS Lic. No. :NSE AND/OR POULTRY RANCHES AND KENNELS ,,,'r 3TRATION MISCELLANEOUS SERVICES Regist. No. .BER e�—? � Color Application Date —1✓✓� /� ?X?- Business/Name To Appear On Permit tcOlrst '5-- w.-M W---, —�c--•- o Type Permit/Service Requested/ _ t S�oYQ._ - —Address ��-._ a Applicant Name s� Busines Telephone No. Emerg ncy Telephone N? _ a ^^Z�77 �j �c -Property Location,Address/ /5Z-J~� it t_�rl�t� /15 � 'eil .£°r F L2Z —..'�W�' 1tgo'_ .�� C4lo�� e Property Owner —)t 6j1C— VZ�l✓7i- � Address Operator's Name Address 1--ua 1r�a �cz �i►xlala3 � � 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. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds "ftF" :ENNEL/Runways /Animal Population No. _.. . _ _ No.of Confining Cages __- Sewage Disposal Method Solid Waste Disposal Method Water Supply Source __ 7A___ __ __ Animal Waste Disposal Method t 6. Jd CONSULTATION FEE 7. ❑ PLAN CHECKING FEE 8. REAL ESTATE REQUEST: Water Well Inspection 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 1 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 S Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED ---- - — . _— AMOUNT FEE ,_ LESS PRORATION PLUS __ _____.. _----- ------ ----- — PENALTY OTHER OTHER