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Applications Will Be Prom-- When Submitted Properly Completed. Be Sur- Ign The Application. <br /> APPLICATION <br /> ENGINEER'S AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONS LIC. No. <br /> Ir.ENSE AND/OR POULTRY RANCHES AND KENNELS <br /> STRATION MISCELLANEOUS• SERVICES Regist. NO..BER <br /> Color <br /> Application Date Z Business/Name T1/�PearGOn Pemit �� lLL / <br /> FType Permit/Service Requeste /7Ty- <br /> Applicant Name./ f �fcrf�•,�iFll�.¢� Address ��CJ - f/�GCG/fi,Q U� <br /> Z e, '4 Business Telephone No. ,�`— 3 yS� Emergency Telephone No.-/lG"27I/ <br /> 'a Property Location/Address <br /> s� .-7�+/ <br /> ePrope rty Own er---L0l49GQy CpDGi- ^S 2;> ✓SFE 6CAddress V1/D/LCC AM /� AP-061-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 /> 13HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCC I]"e`�11d► <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER OUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER +"?- t 1L' <br /> NO. OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHINk0� ?r(Ri-�1C�. <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds Et��k@liT/5 <br /> lip :ENNEL/Runways /Animal Population No. No. of Confining Cages <br /> wage Disposal Method <br /> Solid Waste Disposal Method <br /> Water S ply Source Animal Waste Disposal Method <br /> 6. CONSULTATION FEE !,yp. itiG'e o � � <br /> 7. ❑ PLAN CHECKING FEE !' L E Dc' <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. Seiler 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 rrree�gu�lations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X 7 4 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 8 Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE (� Q UO AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - <br /> R e ea by Date R pt No. Permit No. Issuance Date Malted—Del <br /> iveretl <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE.,P.O.Boa 2009 STOivemd CA 98201 <br />