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Appllcations WIN Be P -%'sed When SubmNW Property Completed.BeS40 Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED,GIVE <br /> APPLICANTS AND/OR FOOD fMTANU MMMTs,110USIMS Make <br /> CONTRACTOR AND/OR PMC re.K,S,WATER SAMPUNG <br /> BROKER AND/OR am E"En <br /> Lic. No. <br /> .ISE AND1000I- Regist.No. <br /> 3T#A"6N <br /> 1. ,aER Color <br /> (Application Date Business/Name To Appear On Permit RA&,.0 P000C <br /> )IType Permit/Senrice Requested: r!��.+�- W�r1r- l_��-Csee_ ate t6 646w <br /> Applicant Name Rey F 0F51rolr. ,live. Address $3 WAIT A -4R(N LAI.. .L'uiti /2- <br /> Sr.nefieaa, CA, 4S►207 Business Telephone No.t2o!I117h1i3S Emergency Telephone No.004)4S2-tl6S <br /> Property Location/Address <br /> 11Property Owner RAav Fsees_lire. Address /"G UvATeec,ee AO. ./�!]r 'zoo, t*4t-- CA-" <br /> -Operator's Name _tAtut_Fe-es /m. r Address o INAlow. o '►2+>w -S fe.44., Ot <br /> 1. FOOD EiTABILISHMItNTS Total Building Sq. Footage Restaurant,Maximum Seating Capacity <br /> ❑ RESTAURANT © FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADWIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> Q-CONFECTIONARY STORE ❑ FOOD.SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/No.of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑.FOOD CROP HARVESTING/No. of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No.of Units ❑ CERTIFICATE OF OCCUPANCY <br /> 0 PARK/No:of$ ,cs �- �] ChIEMICAL <br /> 3. WAATTER ITY' Q WATER SAMPLE (Bacterial) <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER PAYMENT <br /> NO. OF PUBLIC SERVED(Connections) If 19 V ED <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL I] SPA ❑ WADING POOL ❑ NATURAL BATHING P <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds r nh1v q 1 � �� T <br /> r :ENNEL/Rt nways /AnimAI'Population No. No.of Confining Cages + <br /> Sewage Disposal Method <br /> ONMEN I AL HEALTH <br /> Solid Waste Disposal Method PERMIT <br /> Water Supply Source Animal Waste Disposal Method <br /> N <br /> S. I CONSULTATION FEE rev-a- : .-WOR11 PLAoI CrRevrP 604FR AV#T?C&A**0 rt.kRe► f�94&0 60".6,hy-C. �i .leT s�'1�1� S <br /> 7. ❑ PLAN CHECKING FEE <br /> S. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <br /> Escrow No. <br /> Seller Seller Address <br /> Te4wWne No. r Agi W Nares <br /> Service Request For Date <br /> I hereby certify that I have prepansd 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 /> APPLICANTS SIGNATURE X44&=" �r � Title AasdruMf fAeff•L1 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY ❑ PEA UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 6 Received By July 31 <br /> R IT <br /> BILLING REMITTANCE $BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEELESS <br /> PRORATION (�\ I <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> - 1. <br /> Received by Date Rbceipt No. P4rmit No. Issuance Date Mailed Delivered <br /> APPLX*"—IITVM0 M4 Ta: ilEALTI�"11!AM'FiAERYICEB „7 IL Ha�lr C litVR, P.O.ae>,900a CA' <br />