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Applications Will Be Pr used When Submitted Properly Completed. Be S Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/DR PUBLIC POOLS,WATER SAMPLING Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> .Ir-ENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> I, 'GER Color <br /> [Application Date Business/Name To Appear On Permit <br /> FI Type Permit/Service Requested: <br /> u Applicant Name—MQnra-Rp-troltnim Address 0A <br /> a Business Telephone No, Emergency Telephone No. <br /> <Property Location/Address--148"--HWyy _.9_g-,--Maate" - <br /> Property Owner Address <br /> -LOperator's Name Address <br /> 1. 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 /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO, OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> r :ENNEL/Runways /Animal Population No. No, of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> 6. ❑ CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ Sample❑ Title Company SA, 7 <br /> Sewage System Inspection ❑ Address r $�iC}�' 'T�j ' I,4 <br /> �., <br /> Escrow No. t���iY Vii,'!•^ <br /> Seller �li�rieA=.TH4)A/Ul <br /> Seller Addres!1heWork <br /> Telephone No. Seller Agent Name <br /> Service Request For Dr 1 <br /> I hereby certify that I have prepared this application and that will be don in accordance with San Joaquin County <br /> ordinances, state laws, and t'ie's an re ul tions of the San Joaal Health Disx ' t.,APPLICANT'S SIGNATURE X f tle L !Z G <br /> -- Date / <br /> !{h/ FOR DEPARTMENT USE ONLY <br /> Fee IS Due: 11ANNUALLY LJ PER UNIT PER SITE El ❑ January 1 &Recei ed B J Hoar 31 <br /> Y Y ❑ July 1 d Received By July 31 <br /> BILLING REMITTANCE S REMIT <br /> BASE EXPLANATION JA UNT DUE CHECKED <br /> DATE DATE HE ITTED AMOUNT <br /> FEE 105.00 spec ' 21 90 .00 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTYPFNA.T <br /> OTHER DAYS FROM BILLI G DATE. <br /> OTHER _...�...w._.. <br /> Received by Dale Receipt No. Permit No. Issuance Date Mailed Delivered ' <br /> APPLICANT_2NTH21A AI 1 <br />