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A t*M Wo fi{iG ProoevIad W"n d faroportq Conwmod.Be Sure To Sign The Appifeation. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S ANCIOR IF VP?NiCLE INVOLVED.GIVE <br /> 4PPLICANT-S ANO/OR IBM UTat )STA NOW= Make <br /> CONTRACTOR ANWOA /tS m PEELL•WATER SAMYtm <br /> 3ROKEA ANO/OA REAL EBTATE IMWKMXS Lic.No. <br /> i f FNSs ANO;OA PCKTAwatnt aBEttriB tfEaARe RMS Regiat.No. <br /> ;--QTR►TION L 8 OO <br /> ER Color <br /> 'Appircatron DateE x0 BusrnowNeme To Ap ear On Permit ' <br /> Type PermrbServrce Requested: I <br /> tS�YIAC. O✓1 Qn� r G. ✓R C_L6r, i� �, <br /> ;Applicant Name £ r A.t Address ��zf'Y 4016) �r IOas.:.,f n C' 9�5GG <br /> 8ustness Telephone No.WEEmergency Telephone No, <br /> Property LocationiAddress a <br /> or (24 <br /> �6c ra <br /> i Property Owner a Address r f <br /> i '-Operator's Name Address 5" ^- <br /> 1. FOOD IES7A®LISHlAENTS Total Building Sq.Footage Restaurant.Maximum Seating Capacity <br /> 13RESTAURANT 13 FOOD MARKET RETAIL E3FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> _❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> C3 ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR 13ITINERANT RESTAURANT <br /> -+❑ CONFECTIONARY STORE 13 FOOD SALVAGER E3 FOOD DEMONSTRATION ❑ FG`" G VENDOR <br /> C3 VENDING MACHINES/No.of C3MOBILE FOOD PREP,UNIT C1VENDING VEHICLE <br /> FOOD CROP HARVESTING/No.of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operator <br /> N2.[ HOUSING <br /> -43 HOTEL./MOTEL/No.of Units C3 CERTIFICATE OF OCCUPANCY <br /> MOBILE HOME BARK/No.Of Spaces <br /> WATER OIJALITY O WATER SAMPLE(Bacteraal) ❑ CHEMICAL <br /> I ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> O.OF PUBLIC SERVED(Connections) <br /> RECREATIONAL HEALTH C1SWIMMING POOL 0 SPA ❑ WADING POOL 13 NATURAL BATHING PLACE <br /> 5 VECTOR CONTROL ❑ POULTRY FAFIWMaximurn No.of Birds <br /> /Animal Population No. No.of Confining Cages <br /> �_`''NNELlRunwaye _._ <br /> ey. .Je Disposal Method <br /> 5ofrd waste Disposal MOMOd <br /> dater SuAGIY Source Anima!Waste 000381 MethOd <br /> ❑ CONSULTAI' N FEE <br /> 0' KAN CHEMNO fsEE <br /> L. REAL ESTATE <br /> { `SEQUEST: 'Wster Wel Inspection❑ Sampie0 Title Company <br /> f Sewage System in <br /> ® Address Tele.NO. <br /> Escrow No. <br /> [ p�� Seller Seller Address <br /> Telephone No. Sallow Agent Name <br /> I' Service Request For Date <br /> Y. <br /> 14 <br /> I hereby c�rtlty that I hate Prepared b Itpglieatkm and that the work will tie done in areofdanea with Sett Joaquin County <br /> t ordinances state is and rules and raalulatlons Of the Sen Joaqu°^Local h4({�1�� _ <br /> APPLICANTS SIGNATURE X "� TLde.""aa'tST` P{rs ` - Data <br /> Iy <br /> FOR DEPARTMENT UN ONLY <br /> Foe is flYe:❑ ANNUALLY- -❑PLR UNIT � rEn SITE -❑ EACH 0 JWKWV I A rUn1VW*V J&VA"71 MtnMa SY Juy S1 <br /> RDMT <br /> l i BASE I ExPLANATtOtt - <br /> s fes' I BILLING REtdITTANCL - a- - AletDtBfTOa tIEC EO <br /> t DATE DATE MitNTTEQ AMOUNT <br /> FEE <br /> t. <br /> ss <br /> PRORATION . <br /> .PLUS .-. . <br /> QMALTT <br /> i <br /> t ' OTHER <br /> OTHER i <br /> ?. r _R hwa - Oslo _ ase"No rrnnr rye 1MI/RaY aE tOtaul t v _ .. <br /> i � O <br /> •ap w•�••T-A�+�w u f not@ 1fr AWMA�r7ll rPN Tr M�rYImEIA �M� eos7iiY'fMf LtiO •R a�Eat 0 <br />