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L Appllcellon.Will B.Proc....d When Submitted Property Completed. Be Sure To Sign The Appllollon. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENOINEER'S AND/0H1 APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANTS AND/OR Make <br /> CONTRACTOR ANGOR ENVIRONMENTAL HEALTH PERMIT/SERVICES -- <br /> BROKEA AND/OR Lit. No. <br /> LICENSE"o/OR F000 ESTABLISHMENTS.HOUSING <br /> REGISTRATION FU411C POOL WATER SAMNING Regist. NO. — <br /> NUMBER REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES ANO KEXNELS <br /> '7 s- MIsCEELAMEOUS SERVICER n I 1 t. L.I c�rn ,� o n <br /> /Application Date '/ - 1 — U 6 Bu iness/Name To Appear On Permit l�L <br /> .Type Permit/Serv'ce Requested: h �M G V <br /> Applicent Nan rr 11 �/I I-L-1 4 im S : v- Address Lj Lf r� w <br /> _ El �jass T I hh4ne No. r,i"I D Emergency Telephone No. <br /> -iEProperty LocatioNAddrg�s � , Ot-�( 7oil LI -'t' Lb 1 1 <br /> �g W-� 1� A LI i <br /> J Property Owner WI I�fa r n 1 ✓�h Address—3 <br /> Lgperatofs 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 /> ❑ HOTEVMOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces <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/Maximum No.of Birds <br /> ❑ KENNEL/Runways /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method — <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> L FEE ❑ BUSINESS LICENSE <br /> T. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> ft. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tale.No. <br /> Escrow No. <br /> Seller Seller Address <br /> Telephone No. Seller Agent Name <br /> Service Request For Dale <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws.and <br /> r/upbs/and regulations of the San Joaquin Local Health <br /> District. <br /> APPLICANTS SIGNATURE X l -/i+L LiL �� Title SL -E.— Date <br /> FOR DEPARTMENT USE ONLY <br /> FN Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE N 6cm ❑ J..,1 a R.cen.0 By J.ueq Jt ❑ July 1 A Rece x!By Airy 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE f AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE Vr Q-'- <br /> LESS <br /> PRORATION <br /> SUIS <br /> PENALTY <br /> OTHER <br /> OTHER j <br /> A.cer.o by a1. R.e.,w No. Pee,I No luu.rc..0.1. M.a.a D.1.....e <br /> APRICAM—AlTIYN 111.T1IflEl�ib ENYOIONMEWAL HEALTH PEa MITAERviCES 1401 E.N FLTON AYE_P.O.a.�IDA aTOp(TOK U.aID1 M <br />