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Appiloagono tltllN Be Pr( sed When SB�tilted*Gpedy�. Sit T6 Sign The AppNwtlon. <br /> . >, r APPLICATION - <br /> '� ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> B* IF VEHICLE INVOLVED,GIVE <br /> AP1 == FOO:OSTANLINNUM 11111111111111101111 Make <br /> CONTRACTdR AND/OR FLUX to 1111A1iq=AMMJNi <br /> BROKER AND/OR waflyer iosr anm Lic. No. <br /> 01ENSE AND/OR MIN ACM Ai R111IIME1.11 Regist. No. <br /> STRATTON Color <br /> I, .8ER <br /> Application Date r Business/Name To Appear On Permit s i��'' / <br /> Type Permit/Service Requested: 95.3 <br /> .Applicant Name � <br /> Blusio.p9s.Telep one No. — y Emergency Telephone No. <br /> Property Location/Address <br /> Property Owner tflAddress Pill M S3�y <br /> •Operator's Name Address <br /> 1. FOOD ESTAifi ASHMENTS Total Buftng Sq. Footage Restaurant,Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL 13 FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT 13COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE C3 BAR 0 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 HARVEST_ING/No.of Field Employees <br /> ALL APPLICANTS: Total Employees including Operators <br /> Z. HOUSING <br /> ❑ HOTEL/MOTEL/No.of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces <br /> S. WATER QUALITY P. WATER SAMPLE(Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO.OF PUBLIC SERVED(Connections) <br /> 4. RECIIIIIIIIATIOttft HEALTH ❑. SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> s. vwt6*- ❑ POOLTRY FARMOAsidmum No.of Buda r <br /> r .ems JRunways /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 /> S. ) ►CONSULTATION FEE. <br /> T. ❑ PLAN CHECKING FEE <br /> S. REAL ESTATE <br /> REOUEST: 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 <br /> 1 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,a rules and regulatLons of the San Joaquin Local Health District, <br /> APPLICANTS SIGNATURE X _ -- Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 d Received By January 31 ❑ July 1 A Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date No. Penn*Wo. Issuance DI" (Mailed Dellmed <br /> APPLICANT—RETLOON ALL C.OPWA TO: ! 11f 1�rMMlMaYtCis 1x01 a.NAM AV[..P.O.ao=IOOa tTOpRON.CA <br />