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Applications Will Be fttkcesood When Submltied Properly Completed.Be Sm <br /> r" Sign The Application. <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINSERs AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLWANTIS CONTRACTOR a ENVIRONMENTAL HEALTH PERMIT/SERVICES 0 mks -- <br /> ? A Lid.No. <br /> IIKZNSt ANDER Few UTAU Mit1ORR Nousm � e� <br /> REo1sTRAT"IONS wwN Pesti WATER UNrLM �C 1st.No. <br /> NUMBER REALFSTATEIN WICT w Jn- , 5{,<l i color <br /> MLTNT YNCMFS AM NENNEIB -- <br /> rApplicstion Dats (0/7-1 /5(b Business/Name FTooAALpp�ea On Permit <br /> Type PermiUSe"iec F11f/ �C`e�equesl L <br /> Applicant Ni Jul¢-n { AddreSa� c � S <br /> _ Bu 'ness ephone Mp Emeency Tele hone No, n Zf�t <br /> Property Location/Ad <br /> esa <br /> jPMWty O,.nW � l��( A - Address <br /> Addf7J4� 'S TfA(. . <br /> L Operator's Name �'SL ;5, Address 90) A <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. ❑ LIOUOR 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 /> ❑ HOTEL/MOTEL/NO.of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARKINO.of Space <br /> 1 WATER QUALITY ❑ WATER SAMPLE(Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO.OF PUBLIC SERVED(Connections) <br /> e. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Ma dmum No.of Birds - <br /> ❑ KENNEL/Runways /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Dlsooesl Method <br /> Water Supply Source Animal Waste Disposal Method <br /> IL 1A CONSULTATION FEE A T{4'n[k 1261/101 ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> It. 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. Seller Agent Name <br /> Service Request For Date <br /> I hereby certity that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,a las nd uta' of San.(tl�q/squin Local Health District. <br /> APPLICANTS SIGNATURE X \ Title d �r'>~-�'� Data ZL <br /> OR DEPARTMENT USE ONLY ' <br /> Ice 4 Dur t.7 ANNUALLY ❑PER UNIT ❑ PER SITE ❑ EACH ❑ JYN[ry i•Retched By Ja%ery 71 ❑July/a Reco"O DVh*71 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE f AMOUNT DUE CNECRED <br /> DATE /DATE REMITTED ,WgWT <br /> FEE zz& <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ND to-2—gcd 3y� <br /> R[c1nld by DAN R..VI No Pnm,1 No. I...D[N ANd[d DMrwr[d � <br /> Z <br /> AMLN;AM—a[nsNAlLmeMa TO: [N1n1aONY[NTAL NL4TH►ERY1T/a[RY1Cle 1q1[.NA]:[LTON AYl.I.O.ler 1>a aTOCaTOII CA e6101 � <br />