Laserfiche WebLink
Apptic lions will 8e Prt►Ceeeed When Submitted Property Completed Be Sure To Sign The Application <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> . ^E$'5 stip-a IF VEHICLE INVOLVED GIVE _ <br /> �p ,t <br /> _A •c UiB <br /> aNa�P fOeOESTasllBNAlENT1 NDYB <br /> O,r Tia.Na 7aPUBLIC FROIL&HATER SAUftillE Nake <br /> �arlr Ea•Na OP AlIAL!STATE INSFECTIORB <br /> "OULTRIF ItAt1CNEa AND RENIEIs ac Na <br /> -e4s - "s,�7.:, t NHULLANiOVs ila11mill egisi No _ <br /> Color <br /> _ 10 �x4 Via- paw sM'0Ae�, Gos�,f'.gsi <br /> -cc,cat an _a e __�__ r __ SusiAtSfvName To Aooear OR Conner [:Z./ �����••� ieL✓r c-- -�- <br /> -.aePOFMIf aefwce' auestea 5-F-t=/4 T1�al.fL try5rrg'. _ <br /> Z AODiicant Name rr.A�h/ LCUSLtL Atltlr@SS40 dJK ?6F.;-�:... c_A Zw[o <br /> susiriess reteanome NoC+,}fS - � Emergency T@ieonone Na <br /> -CLI-V _ccauon Agaress /1/C L-GrL'aI�/lfAci .r �K���+ eta C�.�Y t.A.��t?�. Zulu,, �A . <br /> t= aero owner G�lctrMrM:l1_ .yr's,i .' �►H2E ,caress !��_a"2s 'f Z ` 'r d <br /> -zerator s"game ..�et?�frA*C? 2160.Ly AAQ&0A-£l_ -naress —."CAkoiff.._ j• <br /> I FOOD ESTABLISHMENTS -alai Building So Footage Restaurant Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL C3 FOOD MARKET NHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT 0 COMMISSARY ❑ -CE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> CONFECTICNARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES filo at ❑ MOBILE FOOD PREP UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING,No of Fteitl Employees _ <br /> ALL APPLICANTS ',Ia Emo:avees Including Operators <br /> 2 HOUSING <br /> ❑ HOTEL MOTEL.No of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK No at Soaces <br /> z WATER OUALITY ❑ WATER SAMPLE fBactenao CZ CHEMICAL <br /> :3 PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> VO OF PUBLIC SERVED tConnectlonsl <br /> a RECREATIONAL,HEALTH ❑ SWIMMING POOL ❑ SPA 17 WADING POOL C3 NATURAL BATHING PLACE <br /> 0R -VECTOR CONTROL ❑ POULTRY FARM/Maximum No of Birds <br /> _ ENNEL,Runways _ _ Anemia,Population No No at Confining Cages - <br /> aewage Disposal Methoo <br /> ! Soled Waste Dtsoosaf Metnoo <br /> Valor SuODIY SOWCe Animal Waste Disposal Method <br /> E I] CONSULTATION FEE <br /> 7 C PLAN CHECKING FRE <br /> a REAL 9STAT1 <br /> REQUEST Water Well Inspection❑ SamcieO Title Company <br /> Sewage System tnsoecuon ❑ Address Tale No <br /> Escrow No -- <br /> Seller �___ Seller Address <br /> -elefanone No Salter Agent Name <br /> Service Reauest for Date <br /> t nereaV cenity that I have prepared this appitcauon and that the worts vnit be done,q accordance with Sten Joaquin County <br /> ordinances state taws Alta rut and►eyafations of the San Joaquin Locat Heann District <br /> APPLICANT'S SIGNATURE X + Tette S �'t� Date L <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due Ca ANNUAL_• © PE4 UNIT ❑ PEP sirE ❑ EACr ❑ aaiwary I a Reesiree ev isnuory at C7 Jufv I a ass-ea By juw)t <br /> FILLING REMITTANCE = REMIT <br /> SASE EXPLANATION A <br /> DATE DATE RFMITTE@ IirOUh1T OIJa CHOCKED <br /> s MOUNT <br /> FEE ..��.�,....__._.__ <br /> .ISYS- <br /> ry <br /> PROpA►iQN <br /> PL�s <br /> ,r~En <br /> r <br /> �K'weU 9Y mala neco-at No Pq,.m a NO inuaPCe nate Mar.04 Daiws sq <br />