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� ^ A <br /> M1 <br /> A r =� <br /> Applications I ds Proteeeed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT GENERAL <br /> a1O1'E11"ANO/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> AJ41LICANrS ANO/OR <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES M.ke <br /> BROKER ANIDrOR Lid.No. <br /> UCEM6E ANWOR N**UTAalls OEMM N*YfIMf Regist.No. <br /> REGIiTRATION PWIX FS"MATE1 SAMPl1M <br /> NUMB" AEAI ESTATE NUIPECTsalf Color <br /> PNtiTfT RAWNES An aE11MELS <br /> MISCMAl1E*Yf SEAMES <br /> (Application Date �11 3 j Business/Name To Appear On Permit <br /> �Type <br /> 1 PePermit/Service Requested: c <br /> ,� <br /> A leant teams '.�-�Inrc i-nainPnr %, 114C Address_ 220 <br /> ---. '-�-t 1� , _ Business Telephone No. a 1 x;20-24? Emergency Telephone No. <br /> Property Location/Address <br /> Owner Address seri Tlr p fl 2nY l G.?� 5tAG1;4;Q;1 C� <br /> �Prop.rty ���1 ��l Corporation �..��.�-�=.— � � � r � . <br /> Q 5201 Address <br /> l Operator's Nam �,�,�,� ;�,f'-'�' <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum SeatkV 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 <br /> 2 HOUSING <br /> ❑ HOTEL/MOTEL/NO.of UMIf ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ M0131LE HOME PARK/No.Of Spao*S <br /> & WATER QUALITY ❑ WATER SAMPLE(Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO.OF PUBLIC SERVED(Connections) <br /> 4. RECREATIOIiAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> s. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds <br /> ❑ KENNEL/Runwayll /Animal Population No. No.o1 Confining Cages <br /> Sews"Disposal McOwd _ <br /> Solid Waste D"l Method <br /> Water Supply Source Animal Wast*Disposal McMod <br /> & ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> IL REAL ESTATE <br /> REQUEST: Water Well Inspection❑ Sample(3 Title Company <br /> Sewage System Inspection ❑ Address Tele.No. <br /> Escrow No. <br /> Seller -_---- Seller Addrews _ <br /> Telephone No. Seller Agent Name <br /> Service Request For Dots <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 rubs and regulations of the San Joaquin Local Health District <br /> k APPLICANTS SIGNATURE X -r "1, �' Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due:❑;AwAPA&.LT. ❑PER.urMT O PSN SITE' ❑ EACH O .wwvr 1 a Racwwd,ep Jrnnry 31 0 Judy I a Rwe vol by Jug 31 <br /> REMri <br /> BASE EXPLANATION BILLING REMITTANCE f AMOUNT Dl1E CHECKED <br /> DATE DATE REMITTED AMOtAFT <br /> FEELESS <br /> PRORATIONere! 044 E40IF: <br /> PLUS <br /> PENALTY <br /> OTHER <br /> �'� w,11 E i4�� •�� <br /> 1 <br /> OTHER <br /> 0 <br /> 0 <br /> Rrco W by os* Receipt No. P•.mit No. Issuance Date Mailed -DoWered Z <br /> Ap/UCANT—RNnM1kK LLG0=MTQ ENVrONMENTAL NEALTH KRMIT/SERVICES 1901 E.HA2ELTON AVE-P.O.Mt JIM fTOCKTON,U SIM r <br />