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9 <br /> ENGINEERS AND OR NV <br /> EIRONMENTAL HEALTH PERMIT/SERVICES <br /> APPLICANTS ANDiOR FOOD ESTABLISHMENTS.HOUSING IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND,OR PUBLIC POOLS,WATER SAMPLING Make <br /> BROKER AND-OR REAL ESTATE INSPECTIONS LIc No <br /> i(-ENSE AND,OR POULTRY RANCHES AND KENNELS <br /> ;TRATION MISCELLANEOUS SERVICES Reglst. No. <br /> �. 6ER / Color <br /> Application Date _1D/Z71��f - ----- Business/Name To Appear On Permit �d.�►/l�j,t/�/ <br /> Type Permit/Service Requested: _ -�[VSJL�Gr7 v�11 Op �v2/-'vey- <br /> <APpllcant Name _ Address �CJ�4 /4d&-2-L-- ST /� jam[ _ �12E _U//� <br /> U <br /> Ile- <br /> CL - - - -- - _- -__ __ Business Telephone No. _y!-?-G5.1-SGSDJ Emergency Telephone No <br /> aProperty Location/Address <br /> ------------ - <br /> aProper;y Owner Address 249/ (/l�_IVfX L1 Q �LUG/ELa� _ <br /> (Operator's Name Address -Z-eZ47-#Wr1Gc 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 ❑ 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-_—___-- PAYMENT" <br /> 2. HOUSING R EC E I V ED <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces i I 188 <br /> 3. WATER QUALITY C1WATER SAKIPLE (Bacterial) ❑ CHEMICAL OC O <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER L� <br /> NO. OF PUBLIC SERVED (Connections) __ __ �NVIRONMENTAL HEALTR <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL 11SPA ❑ WADING POOL ❑ NATURAL BATHIfSG FLAKE`RVICES <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 /> ------ ---------- <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 /> 0)1— <br /> REQUEST: <br /> )LREQUEST: WateF Wal Inspection* Sample C1 Title Company <br /> Sewage System Inspection ❑ Address __-_ Tele. No. <br /> Escrow No <br /> Seller _ Seller Address NY <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 <c�l�C%SC/�N��1 Date <br /> FOR DEPARTMENT USE ONLY <br /> LEVINE•FRICKE C1814Frsonk ofCoStreete 812116 <br /> 1814 Franklin Street 1211 <br /> LEI CONSULTING ENGINEERS AND HYOROGEOLOGISTS Oakland,CA 94612 <br /> 1900 POWELL STREET,SUITE *1200 11726 <br /> EMERYVILLE,CALIFORNIA 94608 <br /> (415)652-4500 <br /> SEVENTYAND NO/100------------------------------------------------------------------ <br /> 1 <br /> DATE CHECK NO. AMOUNT <br /> October 27, 1988 11726 $70.00 <br /> San quin Local Health District <br /> PAY LEVINE•FRICKE,INC. <br /> TO THE <br /> ORDER <br />