COMPLIANCE INFO_1990-2010 - Laserfiche WebLink

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Applications Will Be Prod When Submitted Properly Completed. Be So Sign The Application. APPLICATION ENVIRONMENTAL HEALTH PERMIT/SERVICES ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE APPLICANT'S AND/OR F000 ESTABLISHMENTS. HOUSING Make -_ CONTRACTOR AND/OR PUBLIC POOLS, WATER SAMPLING — —'-' -' BROKER AND/OR REAL ESTATE INSPECTIONS Ir.ENSE AND/OR POULTRY RANCHES AND KENNELS (CRal 3TRATION MISCELLANEOUS SERVICES - -------` I. BER -------t--J---- — /1 / (Application Date _`�_!� —_— Business/Name To Appear On Permit .SAelt ___��51—.— oType Permit/Servi Re Iested: u Appli ant Name _ _ S'S -t s Address /._3_�7_Mr' A_Aee C �� a r�� Business T lephone No. .�gJ �2�---EQ 5f�j_'3_ Emergency Telephone No. a Property Location/Address __ __y%�- — p -1 Property Owner 1 �(-�,j . __. 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/MOTEL/No. 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 :ENNEURunways -- /Animal Population No.. No. of Confining Cages Sewage Disposal Method Solid Waste Disposal Method Water §itply Source _._ Animal Waste Disposal Method 6. �� ONSULTATION FEE 7. V007PLAN CHECKING FEE 8. REAL ESTATE REQUEST: Water Well Inspection Sample[] Title Company Sewage System Inspection ❑ 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. 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 BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE s., 8/21/90 .SJV LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Penis No. Issu. nce Date Mailed Delivered