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1 <br /> �o Sign The Application. <br /> Submitted Properly Completed. Be <br />100IM-A4 <br /> edWhen TfONgppL4CA GIVE <br /> APPticatloIF VEHICLE INVOLVED, <br /> f.� <br /> ENVIRONMENTAL HEALTH pERMITISERY�CES Make <br /> FOOO ESTABLISi1MIENTS,HOUSING LIC No, <br /> PUBLIC POOLS.WATER SAMIPLING <br /> EER5 AND'OR REAL ESTATE INSPEC110N5 Reglst N°. <br /> �rDANT'5 ANDIOR pOUNCH <br /> LTRY RAES AN KENNELS <br /> CONTRACTOR AND OR MISCELLANEOUS SERYtCES <br /> BROKER AND OR _ - <br /> trFNSE AND OR <br /> -TRAT 10�% <br /> � ear On Permit - aXid 94603 - <br /> EiusinesslName TO APP 9220 G St +_-Okl-a- -- n <br /> APPI141"t►on Date - - 1- - Address Emergency Telephone No. - <br /> aTyPe permltiService - <br /> Requested' ConstrUCtl Oil <br /> i Para easiness Telephone No. --� -� - -- _-- - - <br /> a uAPPncanr Name __ - TraCy_- - -�- ---- - - <br /> pattersan_pas�, <br /> 24�Q�i1.- - Address <br /> Q. (Property LocatloNAddress - Address capacity <br /> Restaurant,Maximum Seating <br /> s -Property Owner - - - - ❑ MEAT MARKET <br /> Total Building Sq. Footage <br /> a I Operator's Name [] FOOD MARKET WHOLESALE ❑ BAKERY <br /> I `, FOOD ESTABLISHM 0T'F OD MARKET RETAIL (3 ICE PLANT ❑ ITINERANT RES,,UPANT <br /> 1 ❑ RESTAURANT ❑ COMMISSARY ❑ BAR ❑ 11 VENDOR <br /> E ❑ FOOD PROCESSING PLANT C3 LIQUOR STORE ❑ FOOD DEMONSTRATION ❑ VENDING VEHICLE <br /> [ ❑ ROADSIDE FOOD STAND ❑ FOOD SALVAGER <br /> C C3 CONFECTIONARY STORE - - - ❑ MOBILE FOOD PREP.UNIT <br /> 0 ❑ VENDING MACHINESIN°. of --- to ees <br /> D ❑ FOOD CROP HA of <br /> Inleld ciudingpOPerators _- -- - <br /> 0 ALL APPLICANTS: Total Employees ❑ CERTIFICATE OF OCCUPANCY <br /> AL. 2. HOUSING �- <br /> 2. ❑ HoTELIMOTELINo. of Units <br /> ❑ - <br /> 1 0 MOBILE HOME PARK/No aces .___.-- - ❑ CHEMICAL <br /> ❑ A 3, WATER QUALITY 0 WATER SAMPLE (Bacterial) ❑ WATER HAULER <br /> ❑ SURFACE WATER SUPPLY <br /> s. 1 ❑ PUBLIC WATER SYSTEM _ --- --- - ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> ❑ P NO OF PUBLIC SERVED (Connections)IMMING POOL ❑ SPA <br /> NO 4. RECRFATIONAL HEALTH NO. of Confining Cages <br /> 4. R 5, YECTOR CONTROL ❑ POULTRY FARM/MaMmum No al Birds - <br /> /Animal No <br /> 5. vi F '.ENNELfRunways -- <br /> F ;E Sewage Disposal Method -- --- - —__ ------ - - ----_�— <br /> Sewac Solid Waste Disposal Method -- -- -- Animal Waste Disposal Method <br /> Solid 1 Water SuPPIY Source <br /> Water 6. E(CONSULTATION FEE <br /> 6. 113� 7. ❑ PLAN CHECKING FEE <br /> 7. ❑ g. REAL ESTATE ❑ Title Company - - -- ---� <br /> 6. REA REQUEST Water Well Inspection❑ Sample _Tele. No. <br /> REQUE; Sewage System Inspection <br /> ❑ Address -- -- —- <br /> Escrow No - - - <br /> Seller Address -- -. -- - <br /> Seller - - <br /> - - <br /> Seller Agent Name <br /> Telephone No - - - - -- -- --- -- <br /> Service Request For Date - - - <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 /> APPLICANT'S SIGNATURE X Title -- Date <br /> APPLICAN FOR DEPARTMENT USE ONLY <br /> Fee Is Due_ ❑ ANNUALLY_— PER UNIT ❑ PER SITE ❑ EACH 0—January 1 A Recerved By January 31 ❑ Juty i &RecerveFldBy EMlTuly 31 <br /> Fee Is ExPLANATION 'BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> BASE DATE DATE REMITTED AMOUNT <br /> 35.QQ 1/24/39 <br /> FEE LESS <br /> PRORATION - -- — — -- --- ss►�,ryry P <br /> LESS PLUS <br /> PRORAT PENALTY <br /> (� y� rj� p <br /> 3.50 ._. ___P�!ia1 3/5 aaKK// ✓ <br /> IPL Us <br /> PENALTt OTHFH <br /> OFHER r?FHEH <br /> RNCeI(M ft <br /> ''�LJC+UVT�pET l7.rrr._ � _• ti ..eypi.-. a 'Cff7jr/ —_-- rr• <br /> CAVES T0. <br /> ErvviRON,yENTAL HF4LTHP peF'�'', `! "'-id, C���l� <br />