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71 Applications WIII Be Pro ed When Submitted Properly Completed. Be Sur Sign The Application. <br /> ICATION <br /> > ,i and I Data APprovedENvjA`6hVa TACe I EALTH PERMIT/SERVICES <br /> .ENGINEER'S AND/OR I Payment By: IF VEHICLE INVOLVED, GIVE t APPLICANT'S ANR/OR 'star PaISHMENTS.HOUSING Mak <br /> CONTRACTOR A D/OR PUBLIC POO S.WATER SAMPLING ----- —-- <br /> BROKER AND/0131 REAL ESTAT INSPECTIONS Lic. No. <br /> InENSE AND/ORTRY A CHES AND KENNELS <br /> 3TRATION 62-2a US SERVICES Regist. No. <br /> aER I ERM IT/SERVICES Colo' <br /> [Application Date Business/Name To Appear On Permit Fi5ir.( N C &&S 9 F LPCj-T-LC [ <br /> wType Perm it/Servi Req esd: <br /> E / <br /> uApplicant Name G(.l.i'Ltek '+" -Is 61C ddress Ii�t tlJY'✓ILG�j Sc..n rw-Y,irk 64C <br /> dBusiness Telephone No. — �`lEmergency Telephone No. <br /> 'a Property Location/Address I' 2,n6d. 64 <br /> aProperty Owner NCL-fl C (..a c.JL F'l. L" La Address C�I A r-✓1 L rx�Sr,A F-raL.n U(ep /a <br /> Operator's Name AJ A" Address AJ& <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 RECEIVEp <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces 2 L/tl 1988 <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL OCTL� I J O <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER ENVIRONMENTAL HEALTH <br /> NO. OF PUBLIC SERVED (Connections) PERMIT/SERVICES <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> F !ENNEVRunways /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source CC Animal Waste Disposal�tM�eth`od <br /> 6. CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. 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 /> 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 <br /> rrules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE x Title Cln uT11 S ��GLt/P14n Dale <br /> FOR DEPARTMENT USE ONLY T- <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE E <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT_ <br /> FEE <br /> LESS <br /> PRORATION DAYS ROM BILLIN DATE <br /> PLUS <br /> PENALTY <br /> OTHER LLZI <br /> (J� <br /> OTHER v <br /> eivetl Oy Dale Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETNRN ALL COPIES To' ENVIRONYENTAI NFGI TN DFDYIT/SFDVICFR 1.1 C ..TFI T..eVC Dr. Dn.enm eTNPVTr1u Ce DF9n1 <br />