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2T ' d _1di01 <br /> Applications Will Be pro aad When Submitted Properly Completed. Be Sure To Sign The Appilealion. <br /> APPLICATION * <br /> ENVIRONMENTAL HEALTH PERMIT/SERVIces <br /> IF VEHICLE INVOLVED, GIVE <br /> ENGINEERS ANDr614 <br /> APPLICANT'S AND Uti F000 ESTASLISHMENt3,HOUSING Make __— ----__ <br /> CONTRACTOR AD 09 PUBLIC POOL$,WATER SAMPLING -- _- <br /> BOOKER TOA A REAL ESTATE INSPECTIONS Lic. NO - <br /> I90KE E AND,Ori POULTRY RANCHES AND KENNELS Reglst. No. <br /> 3TRAYION MISCELLANEOUS SERVICES --__ <br /> Color _ <br /> I, aER <br /> �5��� Business/Name To Appear On P <br /> Application Date .... / .�..._. . ..---.. <br /> Type PermiuServlce Requested: G i l✓ - -° -� <br /> ,cAPPlantName Address <br /> //� / (`�, •.•_,••_, Business Telephone No. `Y3 q Emergency Telephone No. —. -- -- <br /> Property at on/Address — <br /> Property Qwnor�¢uin /fv -.�>f�i�e Dwcl_ -�tG� Address .zell. .Gd..._f�tgrc%_ ,h ev S✓ifs O� -L� faC E_fi . <br /> i,Operator'5 Nar'ne <br /> 1. FOOD ESTABLISHMENTS Total Building S 1, Footage Restaurant, Maximum Seating Capacity <br /> ID RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSi0E FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SAI VAGEP ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑'VENDING MACHINES/No. of _ _-- __ ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees - -ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units _.. -_.- [1 CERTIFICATE OF OCCUPANCY <br /> 0 MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM Q SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO OF PU6LIC 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 /> 4. REAL ESTATE - Si/,144.OkD 50'a �oel�Crs �61U/✓7I.UG /�SP�GJJr/YL <br /> REQUEST: Water Well Inspection l3 Sample❑ Title Company _ -- - <br /> Sewage System Inspection ❑ Address __- -.... <br /> .._-Tele. No .. -- <br /> Escrow No ----- - <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. / �g <br /> ?ills _Sev'i /Ul ec.�SG/ �Zte <br /> APPLICANT'S SIGNATURE X ✓- <br /> FOR DEPARTMENT USE ONLY <br /> ❑ July i a Re<:e,ea By JUIY JI <br /> Fea IS fJUe= ❑ ANMJALLY PER UNIT ❑ PER SITE ❑ EACH ❑ .f34uery t R Receivao Ely January 31 REMIT <br /> pASE Ei(PLANATIOI`I DILLING REMlYTANCE 5 A.MOUN-r DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PAC)RATION I - - --- - — - <br /> PLUS <br /> PENAr TrOTHER - <br /> -— <br /> ——.. --- 155uar,Ce Data Mt/Jwd Delivered <br /> Rece y6<'r Gy G <br /> Zlc Re,_e-Pt NO <br /> AVE.,,nzFvon E.,0.0.Sox 2009 9TnC1(TOk,CF,A5?Oi <br />