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Applications Will Be Proc /d When Submitted Properly Completed. Be Sure Sign The Application. <br /> APPLICATION <br /> ENV NMENTAL HEALTH PERMIT/SERVICES <br /> s AND/OR' IF VEHICLE INVOLVED, GIVE I <br /> .NT'S AND/OR FOOO ESTABLISHMENTS. HOUSING <br /> 4ACTOR AND/OR PUBLIC POOLS.WATER SAMPLING Make <br /> ,SER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> ENSE AND/OR POULTRY RANCHES ANO KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> .aER <br /> --' COIOf <br /> l2 /��7�1 G .To b No , 92L-70 <br /> pplication Date <br /> O BusinessiN me To Appear On Permit <br /> ype Permit/Service eques_ted:�u s� <br /> pplicant Name �l �1? 11il- <br /> e�M M rdress F L0zze <br /> 5 � , Usines Tel phone No. Emergency Telephone No. <br /> roperty Location/Addres-s28 G �- u <br /> roperty Owner— dr� ( o1 <br /> perator's Name = Address 3(!f (ti C ©�O <br /> 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 /> LL APPLICANTS: Total Employees Including Operators <br /> HOUSING <br /> I <br /> HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> MOBILE HOME PARK/No. of Spaces <br /> WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> D. OF PUBLIC SERVED (Connections) <br /> RECREATIONAL HEALTH 11SWIMMING POOL C3SPA ❑ WADING POOL 11 NATURAL BATHING PLACE <br /> VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> :ENNEL/Runways /Animal Population No. No. of Confining Cages ! <br /> wage Disposal Method - <br /> .lid Waste Disposal Method <br /> ter S ply Source Animal Waste Disposal M thod j <br /> CONSULTATION FEE <br /> ❑ PLAN CHECKING FEE z _ <br /> REAL ESTATE <br /> QUEST: 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 i <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 /> I <br /> �LICANT'S SIGNATURE X Title Date t <br /> E <br /> e <br /> FOR DEPARTMENT USE ONLY # <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I &Rece ved By January 31 ❑ July 1 &Received By July 31 <br /> REMIT 1 <br /> BASE EXPLANATION BILLING REMITTANCE I $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> PEE 12-4-90 S <br /> LESS I j <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER j �`�rIS <br /> OTHER LIN'G pIL <br /> c PA DUFa d <br /> v I <br /> Recewea by Date Ro I <br /> .Ceipt N Permit Np ISSUanCC Dale Marled Delivered 1 <br />