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a en Submitted Properly Completed. Be Sure' gn The Application. <br /> Applications WIII Be"Protea""`,,Nh <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES IF VEHICLE INVOLVED, GIVE <br /> .NEER'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make <br /> �LICANT'S AND/OR PUBLIC POOLS.WATER SAMPLING <br /> ONTRACTOR AND/OR REAL ESTATE INSPECTIONS LiC. No. <br /> BROKER AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> rcNSE AND/OR MISCELLANEOUS SERVICES Color <br /> 3TRATION <br /> BER M 1 <br /> F / j� /"IGLGJYGh �YI✓irOHiyf2-K! Gn9ivr erg 'rT--- <br /> Application Date 6 1'3 /?"� Bu//���ness/Name To Appear OnLPermit <br /> Type Permit/Service Requested: �orrSu/Ta�iO �e r ✓, 1 — <br /> ✓e ro p ,E.. 'r�Address ///D/ f•J�iiTe leo /�©ac� <br /> =A plicant Name /h G (9/�� 638'3 61901 Emergency Telephone No. <br /> ,,�1•o Cordo✓0. CA �S6Z BuC�ss Tele hone Np. <br /> 2 /S r er a <br /> a Property Location/Address r-. Address ,500 �i�Jer f;ldetiu� ke-,,) <br /> i Property Owner <br /> 42 P1 <br /> •� ir <br /> Operator's Name 60 <br /> l,J o ah c Address <br /> Total Building Sq. Footage Restaurant,Maximum Seating Capacity <br /> 1. FOOD ESTABLISHMENTS 13FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ RESTAURANT 13 FOOD MARKET RETAIL ❑ ICE PLANT ❑ BAKERY <br /> 13 FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ITINERANT RESTAURANT <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR <br /> 13 CONFECTIONARY STORE 13 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 ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ HOTEL/MOTEL/No. of Units <br /> ❑ MOBILE HOME PARK/No. of Spaces ❑ CHEMICAL <br /> 3. WATER OUALITY ❑ WATER SAMPLE (Bacterial) <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 /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> KENNEL/Runways /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Animal Waste Dispos_aJI Method <br /> Water Supply Source / �t <br /> �¢` .� .. rP�o r/ r8✓i e W SiTc_ IJhs� A�o r <br /> 8, (Z CONSULTATION FEE 3S Maur <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample❑ Title Company Tele. No. <br /> Sewage System Inspection ❑ Address <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. <br /> APPLICANT'S SIGNATURE X <br /> Title 1-3 <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMj BILLING I'j REMITTANCE S AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE AMOUNT <br /> RItCEIVED <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ENVIRO MENTAL HEA TH <br /> OTHER <br /> OTHER <br /> c1 >, j. <br /> Permit No. Date Mailed Delivered <br /> Receipt Issuance - Cri Cs 35201 — <br /> Aecerved by Date „c ,.,�c�—AA evc ^^n .. t^m .. <br />