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Applications Will Be Proce When Submitted Properly Completed. Be Sure ' <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />ICE PLANT <br />BAR <br />FOOD DEMONSTRATION <br />MOBILE FOOD PREP UNIT <br />FOOD PROCESSING PLANT 0 COMMISSARY <br />ROADSIDE FOOD STAND 0 LIQUOR STORE <br />CONFECTIONARY STORE 0 FOOD SALVAGER <br />VENDING MACHINES/No. of <br />FOOD CROP HARVESTING/No. of Field Employees <br />ALL APPLICANTS: Total Employees Including Operators <br />2. HOUSING <br />No. of Confining Cages <br />HOTEL/MOTEL/No. of Units 0 CERTIFICATE OF OCCUPANCY <br />MOBILE HOME PARK/No. of Spaces <br />3. WATER QUALITY 0 WATER SAMPLE (Bacterial) 0 CHEMICAL <br />PUBLIC WATER SYSTEM 0 SURFACE WATER SUPPLY 0 WATER HAULER <br />NO, OF PUBLIC SERVED (Connections) <br />RECREATIONAL HEALTH 0 SWIMMING POOL 0 SPA 0 WADING POOL 0 NATURAL BATHING PLACE <br />VECTOR CONTROL 0 POULTRY FARM/Maximum No. of Birds <br />r :ENNEL/Runways /Animal Population No, <br />Sewage Disposal Method <br />Solid Waste Disposal Method <br />Water Supply Source <br />0 CONSULTATION FEE <br />0 PLAN CHECKING FEE <br /> Animal Waste Disposal Method <br />Title Company <br />Address -- <br />Seller Address <br />Seller Agent Name <br />Tele. No <br />REAL ESTATE <br />REQUEST: Water Well Inspection 0 Sample 0 <br />Sewage System Inspection 0 <br />Escrow No. <br />Seller <br />Telephone No. <br />Service Request For Date <br />Date Title APPLICANT'S SIGNATURE X <br />. . . APPLICANT—RETURN : <br />FOOD ESTABLISHMENTS, HOUSING <br />PUBLIC POOLS. WATER SAMPLING <br />REAL ESTATE INSPECTIONS <br />POULTRY RANCHES AND KENNELS <br />MISCELLANEOUS SERVICES <br />ign The Application. <br />IF VEHICLE INVOLVED, GIVE <br />Make <br />Lic. No <br />Reg ist. No <br />Color <br />ENGINEER'S AND/OR <br />APPLICANT'S AND/OR <br />CONTRACTOR AND/OR <br />BROKER AND/OR <br />IrENSE AND/OR <br />3TRATION <br />I. .8ER <br />[Application Date <br />co Type Permit/Service Requested:_ <br />Applicant Name <br />7.1 a. <br />gclE Property Location/Address <br />Business/Name To Appear On Permit <br /> Business Telephone No. <br />Address <br /> Emergency Telephone No. <br />Property Owner <br />'[Operator's Name <br />Address <br />Address <br />1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br />RESTAURANT 0 FOOD MARKET RETAIL 0 FOOD MARKET WHOLESALE 0 <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 />MEAT MARKET <br />BAKERY <br />ITINERANT RESTAURANT <br />FOOD VENDOR <br />VENDING VEHICLE <br />Fee Is Due: 0 ANNUALLY <br />FOR DEPARTMENT USE ONLY <br />0 PER UNIT 0 PER SITE 0 EACH 0 January 1 & Received By January 31 0 July 1 & Received By July 31 <br />BASE EXPLANATION BILLING <br />DATE <br />REMITTANCE <br />DATE <br />$ <br />REMITTED AMOUNT DUE <br />REMIT <br />CHECKED <br />AMOUNT <br />FEE <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER (4 )I. <br />------------------------.. Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br />_ _ ..-.. -.. ---...-- --- .•— ... n- nnnn e•rese.lel-nu -- —....... .-. ........,, n n - ,w ocIn1