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Applications Will Be Processed When Submitted Properly Completed. Be S--To Sign The Application. <br /> r - <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> FNGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING [ ---- <br /> BROKER AND/OR REAL ESTATE INSPECTIONS <br /> o <br /> .IrENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES ist. o. <br /> I. .dER Color _ <br /> [Application Date Business/Name To Appear On Permit — <br /> InType Permit/Service Requested- <br /> z. <br /> equested: <br /> UAp ant a e ��i�_/'ZPi'ZQ � CC�/!/e —.----- Address 0V <br /> U: <br /> — —�v— Business Telephone No._�/-5 y,4=/_7-S2rmergency Telephone No. <br /> a Property Location/Address <br /> ` <br /> a Property Owner_�� P�{�1�u_if � _ Address (, J <br /> Operator's Name 1e[_C j y�q/_�� Y! cccrs —_ Address . ��s— �� � <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 ❑ i-NNERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION FOOD VENDOR <br /> 11 VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. U ❑ VENDING VEHICLE <br /> 11 FOOD CROP HARVESTING/No. of Field Employees _. 6aS 0 `/]p %57AApp <br /> ALL APPLICANTS: Total Employees Including Operators _ / <br /> 2. HOUSING <br /> Yerlu cel--+C r•f <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 Su ource Animal Waste Disposal Method <br /> 6. CONSULTATION FEE ' Gt�c� <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection El Sample Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <br /> Escrow No. ---- <br /> Seller <br /> __Seller __— __ Seller Address <br /> Telephone No. Seller Agent Name <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 /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE E REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> o7 �S //I— . 1V <br /> FEE <br /> - -3,57r 01) / �3/q S 770.0 <br /> LESS <br /> PRORATION <br /> PLUS ��ry� p nn �-^TO-- <br /> /�(��r�I '� /�/'� ���T <br /> PENALTY _.F _ TIES W1LLB _PP_UED-TO- -AST-DU-F—Ac Q-Ul-Y-t <br /> OTHER DAYS, FROM BILLI qG DATE. <br /> OTHER <br /> Received by Date eipt No Permit No Is; Date Mailed Delivered <br /> ^n(71 rI`�uT—pFTirnl,l At_I r,0DIFQTn' CNIn._t1NUe�1T/Ir 11x111 Ty I`�n•.r�•.•rn,rrrr.. . . _ ,. �� ..... , .- ..- .- _, __ ..._... _ .,_.- <br />