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t Applications Will Be Preld When Submitted Properly Completed. Be Soo Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> NEER'S AND/OR IF VEHICI V <br /> LICANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING Make . ____ <br /> RACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> ER AND/OR REAL ESTATE INSPECTIONS Lic. No. _._ - - <br /> ---- If <br /> SE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> BER 2_ _ Q Color -- -- - - - <br /> Application Date 1- -C��_____ _ Business/Name To Appear On Permit - <br /> u)Type Permit/Servi a Requestef}d:�-�- 1 2- <br /> `A licant Name_�71� rN v Lto1j).1�4( 1-11t"LL�N�. 1�L-•_. Address-l'033 W,'n 1/0 <br /> U <br /> _ -- _U Co .Y.4 qa 4,9-PBusiness Telephone No.__--__ __ ------- Emergency Telephone No. _ <br /> a Property Location/Address _- <br /> `Property Owner _.l5tff-,LL-©1L-,.1w_ _ _ _ - _ Address <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 /> RECREATIONAL HEALTH ❑ SWIMMING POOL 11SPA 11WADING POOL-❑ NATURAL BATHING PLACE <br /> ECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds - <br /> .ENNEL/Runways -_-_ ________ /Animal Population No. No. of Confining Cages_ <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source _.._ _ __1'/ .�_ 71_ Animal Waste Disposal Method <br /> 6. gCONSULTATION FEE JbL-_ 1 '�L�L T � L� n«� ___ ��► G`L�3 _ <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 /> 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 &Received By January 31 ❑ July 1 &Received By July 31 <br /> —� REMIT <br /> BILLING REMITTANCE E <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> --- - -------- AMOUNT <br /> - - ------- --- - <br /> FEE <br /> LESS <br /> ' RORATION <br /> PLUS -------- J LL iLTF LIC:. f I ACCOUNTv .. <br /> PENALTY DAYS <br /> -'" I I INN D <br /> ATE <br /> OTHER M� () 4 <br /> }�-Q <br /> oTHEH 3J3.0f 89 - - -----_-.�. - ---� 19 2•� <br /> Heceived by Date Receipt No Permit No Issuance Date Mailed Delivered <br />