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AppkCN/0na will Of Pfouaeeo When Subr Al" Properly CompletW. 11e ►we to -an IM AppMcatgn. . . . <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />t.loerslRt AND/OR IF VEHICLE INVOLVED, GIVE <br />vrLtCArrty ANO/001 Tees ESTAaUUMEMTS. 0"904 Make <br />DoNTAACT011 ANDIOR PUBLIC Paas& WATER SAMPLING <br />EAOKEA AND/OR REAL ESTATE INSPECTHMS Lk. No. <br />UCENsa ANO/Oft POULTRY RARCMES AMS KENNELS Regist No <br />tEOMYTIATtON . MISCEUANEWt ADtMS <br />106" ' - � Color <br />Application Deli — "To MWuion P J <br />Type PennIVSeMu ,,,,�.,:.. <br />Applicant Name `' ... - eM <br />�..,. BualrlsasNo. I�PIE <br />TOOEEe N0.: <br />Property LocatloWAddrejs <br />Property Owner%/!� Addrees /11 <br />Operator's Name �. % T-�� Address -2-V3 - <br />1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant. MaxMNafn Besting C" <br />❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE 0 MEAT MARKET <br />❑ FOOD PROCESSING PLANT 0 COMMISSARY 0 ICE PLANT 0 BAKERY <br />❑ ROADSIDE FOOD STAND 0 LIQUOR STORE 0 BAR 0 ITINERANT RESTAURANT <br />❑,CONFECT101ilARY. � STORE. O, FOOD SALVAGER 0 FOOD DEMONSTRATION 0 FOOD VENDOR LENDIN131AACHINESMo. Of'' - <br />(( MOBILE FOOD PREP. UNIT 0 VENDING VEHICLE <br />0 FOOD CROP HARVESTING/No. of Field Employees <br />ALL APPLICANTS: Total Employes Including Orators --_ <br />2. HOUSING <br />0 HOTEE/MOTELM0. of Units 0 CERTIFICATE OF OCCUPANCY <br />❑ MOBILE HOME PARK/No. of Spaces _ <br />2. WATER DUALITY 0 WATER SAMPLE (Bacterial) 0 CHEMICAL <br />❑ PUBLIC WATER SYSTEM 0 SURFACE WATER SUPPLY 0 WATER HAULER <br />NO. OF PUBLIC SERVED (Connections) <br />a. RECREATIONAL HEALTH 0 SWIMMING POOL 0 SPA 0 WADING POOL 0 NATURAL BATHING PLACE <br />L,.VECT R�ROL „0 POULTRY FARMnMaximurn No. of 119 �_ �., <br />,r'.k. a . ' r - riNK't.d" NO:: ° �` F . , ,T. �. - Y •r' , <br />Q ICENN r" `/Animal POpulatioh-No No. WConflninpCWes <br />Sewage Disposal Method <br />Sold Waste Disposal Method <br />Water <br />err Supply Source Animal Waste Disposal Method <br />6.% <br />7. Q -PLAN CHECKING FEE 3� <br />a. 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 />Ser.lce Request For Date - -- <br />I hereby certify that I hove 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 />APPLICANT'S SIGNATURE X _ L_ _. qE.Title Date <br />-W'✓_-. 2r��"���- <br />Fee IS Due: ❑ ANNUALLY <br />❑PER <br />FOR DEPARTMENT <br />UMT ❑ PEA SITE ❑ EACH <br />__. . <br />.___ __I -- - <br />USE ONLY <br />wee <br />0 ;Anry 1 a AAI: By JaewrY <br />71 0 J1Ay I a <br />IEecw+ee By July 31 <br />— — <br />' <br />--_ <br />REMIT <br />BASE <br />EXPLANATION BILLING <br />DAY( <br />REMITTANCE <br />DATE <br />L <br />REMITTED <br />AMOUNT DUE <br />CHECKED <br />AMOUNT <br />LESS ON <br />✓1115 <br />IH ..AL1• <br />III.�C N,f/f <br />/S JV r� <br />