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.+ Applications Will Be Pl sed WhenjSubmitted Property Completed. Be S� To Sign The Application. <br /> APPLICATION 11 <br /> r ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR ii <br /> r IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR - FOOD ESTABLISHMENTS.HOUSING i II ;y • <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING I r Make <br /> r BROKER AND/OR - I - LIG. NO. ,I <br /> REAL ESTATE INSPECTIONS } <br /> +r.FNSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATIONMISCELLANEQUS SERVICES <br /> Reglst. No. <br /> I. .t3ER <br /> Color <br /> [Application Date Bu iness/ a Tp Ap ear On P rmit <br /> a <br /> -� _ 1� n <br /> Type Permit/Servic Requ ted. / ,/ <br /> a Applicant Name le"II c/ (/-e'C!'i�' S Address <br /> l] r <br /> a Buslne sTe ephon �,lr/— eV Emergency Telephone No. ; <br /> ro ert,Iodation/Ad res y d ; <br /> aProperty Owner / > ttdress i C v! <br /> [Operator's NameAddress 0. <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity , <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE it ❑ 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;i ❑ 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 /> . ❑ HOTEL/MOTEL/No. of Units 0 CERTIFICATIIOF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces k <br /> 3. WATER OUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) I <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ':❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> .ENNEL/Runways /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method J <br /> Solid Waste Disposal Method <br /> Water Supply Source <br /> I f <br /> Animal W ste Disposal Method <br /> 6. CONSULTATION FEE <br /> 7. El PLAN CHECKING EEE I�' �` • <br /> 8. REAL ESTATE + I <br /> REOUEST: . Water Well Inspection 11 Sample❑ Title Company <br /> r <br /> Sewage System Inspection ❑ Address Tele. No. I <br /> Escrow Na. <br /> Seller Seller Address <br /> i ri <br /> Telephone No. . Seller Agent Name <br /> Service Request For Date I _ <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 Title a 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 BILLING REMITTANCE Sh AMOUNT DUE CHECKED <br /> DATE DATE } REMITTED AMOUNT <br /> FEE <br /> LESS J. <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER ! <br /> _ OTHER <br /> Received by Date Receipt No. Permit No. .I Is$uanCe Date Mailed Delivered j <br />.. .a441 lf.`A a,T-,4FT1 iQ 4.� rn41CC TA•"R"'GIJUIp 111.l�14AIT♦, uCwl TN pFfJHITII ♦ick,tnu•u� 4n a cv.ti 7 <br /> - CFAllll_GC' _ iRn1_iC.u -...lrtnP •"4�'/u /`�PS^.�!-___._ <br />