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Applications Will Be ProcWhen Submitted Properly Completed. Be Sur *woe ;ign The Application. APPLICATION ENGINEER'S ANO/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING IF VEHICLE INVOLVED, GIVE CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING Make BROKER AND/OR REAL ESTATE INSPECTIONS LIC. No. JnFNSE AND/OR POULTRY RANCHES AND KENNELS 3TRATION MISCELLANEOUS SERVICES Regist. No. I. .dER Color [Application Date Business/Name To Appear On Permit —. W Type Permit/Service Requested: _ iUppicant NamAddress Business 1 Telephone No. Emergency Telephone No. n `<Property Location/Address _ iProperty 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/MOTEUNo. 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 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds r :ENNEL/Runways /Animal Population No. No. of Confining Cages Sewage Disposal Method - Solid Waste Disposal Method Water Supply Source Animal Waste Disposal Method 6. ❑ CONSULTATION FEE 7. ❑ .PLAN CHECKING FEE B. REAL ESTATE REQUEST: Water Well Inspection 11 Sample Title Company Sewage System Inspection Cl 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 8 Received By July 31 REMIT BILLING REMITTANCE $BASE. EXPLANATION AMOUNTDUE CHECKED DATE DATE REMITTED jj�� p`p �/�y ' AMOUNT_ FEE O.U��''U f1 ct ,J % V\I3 1O. LESS PRORATION _ PLUS PENALTY ' �^7 SX /�?� /1�\ OTHER "10- LTD In �;.SV « X.ID I� � ID 'cRD OTHER D(�.(J Received.by Dale Receipt No. Permit No. Issuance Date Mailed Delivered ......... ------— ," ---- --.,...«..,.,«.,.,,..« —.e ...00,.n...oe en e.._. e,,. '.