Laserfiche WebLink
V <br /> F <br /> Applications Will Be Procalaed When Suhmstled Properly Completed.Be Sure To Sign The Appliealia, <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> c'+G.NE�P g ANo rp <br /> .--NTMAr�S AND C FOOOISTABUfNN1NT8.ROLZINIB IF VEHICLE INVOLVED,GIVE <br /> "y�aAr•7;,a ANO Cp <br /> 3a+nKEa AND Oa PUBLIC POOLS.WATER SANptINB Make _ <br /> - SE ANo^R HEAL ESTATI INSI"ECTIONa <br /> ,ar C., FJ POULTRY aANCN1i A00 4101111113 LIC NO <br /> MISCEILANICUSSERYICei peglst NO <br /> _ Color . <br /> - <br /> ACCrICailCrt Laie <br /> Elus+n 4lSrNdme r0 ACAedr On awrm+f .- <br /> .-.oe ao+R,ll Serwce aecuesleo 5�r'rrL T�FeI�" ��u �tyrC .�� <br /> jAPAIICanI Name Address ?i0. CBolc <br /> _q_ —_-- _-- Business releonone pro <br /> -."ce•,v _CCarlon ACITess /vt:. L L�{J /NAS H,Z -R�V Emergency Telepnone No <br /> AertvCwner G_(L /FKlI <br /> i 7 yt Z �.t,r�tZE Aadrass - <br /> aerator sHama Adaress pt44y <br /> 1. FOOD ESTABLISHMENT3 J Totat Bult0ing So.Footage Restaurant.Maximum Seating <br /> W Capacity <br /> RESTAURANT ❑ FOOD MARKET RETAIL © FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT <br /> ❑ ROADSIDE r-OCD STAND ❑ LIQUOR STORE 13 BAR 13C3 ITINERANT <br /> I NEAAN7 RE5TAURANT <br /> CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> © VENDING MACHINESrNo.of MOBILE FOOD PREP UNIT C3❑ FOOD CROP HARVESTING,No of Field FmDleyees _ VENDING VEHICLE <br /> ALL APPLICANTS 'atal EmMovees Including Operators <br /> 2. HOUSING <br /> HOTEL.-MOTEL Na of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARKiNO at Soaces <br /> {` 3. WATER f3UALITY ❑ WATER SAMPLE(Sacterlao ❑ CHEMICAL <br /> 3 ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULIER <br /> NO OF PUBLIC SERVED IConnectlonsl <br /> s. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA . ❑ WADING POOL C3 NATURAL BATWING PLACE <br /> EC?OR G0NTR0➢, ❑ POULTRY FARM/Maximum No.of Birds <br /> •�ENNELRunways _ Animal Poputatlon No. No.of Confining Cages <br /> -ewage Disposal Metnod <br /> Solid waste Disposal Method _ <br /> voter Supply Souris Animal Waste Disposal Method <br /> 6. C] CONSULTATION FEE <br /> 7 : G PLAN CHECKING FEE <br /> 8, <br /> REAL ESTATE <br /> t REC3LlE5T Water Well Insooction❑ Samwe❑ Title Company <br /> Sewage system Inspection ❑ Address <br /> Tel*. N.O. <br /> Escrcw No --- <br /> Seller <br /> ---- - Seller Address <br /> Teleonone No SeuQr Agent Name <br /> _ Service Reduest For Data - <br /> I nere0y Certily tnat l haus prapAred this oppliCalion and that the work will bei done in accordance with San Joaculn County <br /> ordinances.state laws.8 d r'JI and rVullations of the San Joaculn LOCaI Health Distrtet. <br /> APpLwCANT'S SIGN <br /> ATURE X Titre-SvlcmDate <br /> L. <br /> FOW DEPARTMHNT UeE ONLY <br /> Feet 15 QUO: C3 Ar-7NNUAL_" ..0 PEP UNIT .❑PER SITE -C3 EACH- ❑ Janysiv &R <br /> 0 ad avian ]l.. <br /> ... ❑July 1 A Reewwoo ar July 31 <br /> - gASE EXPLANATION 13ILLINGREMITTANCE ->< - .REMIT <br /> DATE DATE REMITTEC. AMOUr7TDUE CHECKED <br /> AMOUNT <br /> =EE <br /> _ESS <br /> aRORA TION. - - <br /> ENA <br /> - <br /> �.✓°ENALTr <br /> - PeCNweo Or _. ]ale ReClial No P(iIma Na IalWnCe Dile IYlalll0 DMneree - I <br /> r- <br />