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Applications Will Bused When Submitted Properly Completed. BTo 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 Make <br />CONTRACTOR BROKER A D/OR AND/OR ` G's 1 REAL ESTATE INSPECTIONS PUBLIC POOLS, WATER Pll�� n Lic. N0. <br />DENSE AND/OR v� POULTRY RANCHES AND KENNEMECEIVED Regist. No. <br />3TRATION MISCELLANEOUS SERVICES g <br />I. .dER t? C i 1 9 19{18 COIOr <br />[Application Date ?'dg -20 Business/Name To Appear On Permit <br />SR �0�"C% <br />oType Permit/Service Requested: /n s Z," F', It -- , L. c r. <br />e Applicant Name�fSe�V (!�j?S fo�(P(�r-Ct/y! /�G" 4ddress <br />a <br />/-J Business Business Telephone No. Emergency Telephone No. <br />a Property Location/Address /� / <br />J Property Owner ress �/&CG /� &ell -;Re r'.dA� <br />Operator's Name Address <br />1. 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 ❑ 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 i�h �� / "" , S�Zi( Cc <br />ALL APPLICANTS: Total Employees Including Operators / 1G," -��sG�`/�. <br />2. HOUSING Gl li <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 ❑ WA R HAULER <br />NO. OF PUBLIC SERVED (Connections) <br />4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPAWGOOLNATURAL BATHINGPLACE <br />5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. or :ENNEL/Runways /Animal Population No.onfining Cages <br />Sewage Disposal Method <br />Solid Waste Disposal Method <br />Water Supply Source nimal aste Disposal Method <br />6. ❑ CONSULTATION FEE <br />7. ❑ PLAN CHECKING FEE <br />8. REAL ESTATE <br />REQUEST: Water Well Inspection Sample[] Title Co y <br />Sewage System Inspection ❑ Addre Tele. No. <br />Escrow No. <br />Seller Seller Addr ss <br />Telephone No. Seller Agent Na e <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 />BASE <br />EXPLANATION <br />BILLING <br />DATE <br />REMITTANCE <br />DATE <br />$ <br />REMITTED <br />AMOUNT DUE <br />REMIT <br />CHECKED <br />OUNT <br />FEE of 00 <br />n <br />`� <br />/ <br />/ 904 <br />0 <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />Received by Date eipt No. Permit No. ISAW, Date Mailed Delivered <br />