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ENGINEER'S AND/OR <br />APPLICANT'S AND/OR <br />CONTRACTOR AND/OR <br />BROKER AND/OR <br />.IrENSE AND/OR <br />3TRATION <br />I. .6ER <br />r <br />Applications Will ^ocessed When Submitted Properly Completed.ure To Sign The Application. <br />APPLICATION 4 <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />FOOD ESTABLISHMENTS, HOUSING <br />PUBLIC POOLS, WATER SAMPLING <br />REAL ESTATE INSPECTIONS <br />POULTRY RANCHES AND KENNELS <br />MISCELLANEOUS SERVICES <br />IF VEHICLE INVOLVED, GIVE <br />Make <br />Lic. No. <br />Regist. No. <br />Color <br />Application Date LA --2--]—L)-'qfl Business/Name To Appear On Permit V��> C -A- R(_1 be -A J <br />Type Perm it/Ser v' a Re ueste : a <br />c Applicant Name Ad ess AeW—✓t <br />`(d Business Tel phone No. - Emergency lephone N . <br />7�aProperty Loca Addres S t� <br />!!! <br />aProperty Owna 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 ❑ FjpgQ f <br />1:11.J <br />VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT 1:1g <br />❑ FOOD CROP HARVESTING/No. of Field Employees <br />ALL APPLICANTS: Total Employees Including Operators APR 3 0 1Q9� <br />2. HOUSING <br />❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF <br />C3©�CPC�VI <br />ENTAL HEALTH <br />MOBILE HOME PARK/No. of Spaces O M <br />3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL PERMIT/SERVICES <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 Waste Disposal Method <br />6. ❑ CONSULTATION FEE -- <br />T. PLAN CHECKING FEE '61 Yf� <br />8. REAL ESTATE <br />REQUEST: Water Well Inspection 11 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 <br />Title <br />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 />BASE EXPLANATION <br />BILLING <br />REMITTANCE <br />$ <br />AMOUNT DUE <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEE <br />IIO� <br />�— <br />� ( <br />L I �o <br />Jr <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />n' <br />qu <br />Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br />1 <br />.t <br />