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APPLICATION <br /> ENGINEER'S AND/OR ARONMENTAL HEALTH PERMIT/SERVIO3 <br /> APPLICANT'S AND/OR <br /> CONTRACTOR AND/OR FOOD ESTABLISHMENTS.MOUSING IF VEHICLE INVOLVED, GIVE <br /> BROKER AND/OR PUBLIC POOLS,WATER SAMPLING Make -- <br /> JrFNSE AND/OR REAL ESTATE INSPECTIONS --._ _.--. <br /> 3TRATION POULTRY RANCHES AND KENNELS Lic. No. _._ _ <br /> 1. .aER MISCELLANEOUS SERVICES Reglst. No. _. <br /> Color <br /> [Application Date ' -6/4188 <br /> c/a/uu BUSiness/Name To Appear On Permit Marlowe Properties <br /> Type Permit/SerYce Requested: -Lull - <br /> D jimecir <br /> AppllCant Name_Me-lvin Marl owe /,�/ <br /> .Ackki4ss P.O Rox: 211 - San Rafael CA 94915 <br /> Business Telephone No415-457 2151 <br /> Property Location/AddressRQEla . Emergency Telephone No. <br /> i Property Owner Marlowe Pron <br /> L Operator's Name AddressPte, San Rafael, California <br /> 1. FOOD ESTABLISHMENTSAddress <br /> Total❑ RESTAURANT 13 FOOD MARKET RETAILding Sq❑F FOOD MARKET WHOLESALE otage Restaurant,MaximSeatingCapacity <br /> ❑ FOOD PROCESSING PLANT 13 COMMISSARY ❑ MEAT MARKET <br /> ❑ ROADSIDE FOOD STAND ❑ ❑ ICE PLANT 11 BAKERY <br /> ❑ CONFECTIONARY STORE ❑ F OOOD SD S SALVAGERTORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> El VENDING MACHINES/No. of F ❑ FOOD DEMONSTRATION 11 FOOD VENDOR <br /> C1 MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field <br /> ALL APPLICANTS: Total Employees Including Operators._ <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units H w w <br /> ❑ MOBILE HOME PARK/No. of Spaces ❑ CERTIFICATE OF OCCUPANCY Z W Co lJ <br /> W > a > <br /> 3. WATER QUALITY ❑ WATER SAMPLE((bacterial) ❑ CHEMICAL <br /> F-- w <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY 13 �. W •-1 w <br /> NO. OF PUBLIC SERVED (Connections) WATER HAULER V <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLA F e <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds a I <br /> r :ENNEURunways _ /Animal Population No. >Z <br /> Sewage Disposal Method ----- No.of Confining Cages <br /> Solid Waste Disposal Method <br /> Water Supply Source <br /> S• CONSULTATION FEE 4e5 Animal Waste Disposal Method <br /> 7. ❑ PLAN CHECKING FEE <br /> S. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ Sample❑ Title Company <br /> Sewage System Inspection ❑ <br /> Escrow No. Address <br /> _ Tele. No. <br /> Seller_____ <br /> Telephone No. - - Seller Address <br /> ---- Seller Agent Name <br /> Service Request For Date <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. y <br /> APPLICANT'S SIGNATURE X <br /> Title 4—;' F/L_ -- ,._ Date "f o acv <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH <br /> ❑ Janua1 6 fleceived ey January 31 ❑ July I A Received BY July 31 <br /> BASE EXPLANATION BILLING REMITTANCEANCE 5 REMIT <br /> 1 DATE DATE REMITTED AMOUNTOUE CHECKED <br /> FEEJ� AMOUNT <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Sig <br /> 1777 <br /> Date Receipt No. Permit <br /> APPLICANT—RENo.TURN ALL COPIES TO: EMy1RONMENTAL HEALTH PERMIT/SERVICES I"uenoe Data Wiled peiky� <br /> 1 W 1 E.HAZELTON AVE,P.O.Sea Bode STOCKTON,CA NU <br />