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APp1lc.t Preeeaaed When SMbmet.d PTop.ny Cempl(tad.*Ara To algin Th.Appllcatlem <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> AMICANfI AND.gR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> A►RIG -' <br /> CONTRACTOR ANaMake <br /> oR ENVIRONMENTAL HEALTH PERMIT/SERVICES -- <br /> aROKER AND?OR Lid.No. <br /> LICENSE ANO OR fees MAKMMMM MM" <br /> WEOMTRATKMN ►MMIC POK&WATER SAMHEM Regisl. NO <br /> MUMMER REAL ESTATE IM PECIIME Color <br /> ►MILTST RAMCI ES AM KENNELS <br /> e�� d "MMLAMEMY SERVICES <br /> rApplication Date S-/Q7{i. Business/Name To Appear On Rermlt <br /> .Type PermiVSeNice equ steel: ILAAuAT - - .— <br /> A Ikant Nanta Address <br /> po � <br /> Business Telepflg"Not. Emergency Telephone � <br /> J Properly Location/Address,��Q WP6,e JP .s/ .fT—l�r6N CwLa' <br /> �P1operty � <br /> own»r o /RJ Na .-std Aaaresa 1/2 8 W 4 AqcA& <br /> I.Opentora Name Rl �wdlRlltAQ Address tfAj/�O-9.-� S�hgs�fif _S�DeNatyTy/1 <br /> 1. FOOD ESTABLISHMENT& Total Building Sq. Footage Restaurant.Maximum Sealing 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 /> ❑ HOTEL/MOTEUINo.of Links ❑ 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/Masimum No-of Birds <br /> ❑ KENNEL/Runways /Animal Population No. No.of Confining Capes <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> A.�j❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7.X PLAN CHECKING FE d ❑ DANCE PERMIT <br /> S. REAL ESTATE <br /> REQUEST: Water Wall Inspection❑ Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tele.No. <br /> Escrow No. <br /> Sailor Seller Address <br /> Telephone No. Seller Agent Name <br /> Service Request For Date <br /> I hereby certify that I have prepared this application and that the work wlil be done in accordance with San Joaquin County <br /> ordinances,state laws,and rubs and regulations of the n Joaquin Local Health District. <br /> APPLICANTS SIGNATUR Title 1����--� Date <br /> I FOR DEPARTMENT USE ONLY <br /> Fee H DUN:O•ANNUALLY ❑PER UNIT ❑ PEA BITE ❑ EACH ❑ Jwlwry t s RecoNed By JM 31 ❑Jvly I♦RacwrM ftAft 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AM LPHT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER I/ <br /> f4C.,r.d or MH RK.,pI NO Pwrm.l No IuwM.MH WAW DNrwrtl � <br /> 11RICAM-11CTWKALLfdIMI TO 1N %AONMINTAL HIALTM.[NYII1Sf AVICfa 1"1 E.NAl(LTON AY!_P.MI 1000 STOCa TON CA r6lel <br />