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eNGNEEb 5+ LPIV If1LJlYMCW I AL MLAL i M ermmi I,br_HvjL.t1 <br /> Np rJp <br /> iCRS rAINTgACT S Op <br /> .ONT4A(;Tt;p;+0 Op Teoe ESTASGlNAA[NTi N@UslNt IF VEHICLE INVOLVED GIVE <br /> ROM f a ANO Oq field■ATER Sa4�tlNa �Aas<e <br /> REAL I <br /> ��N5E AMD pq REAL lTATE IMSr'ECTitN1 L C NO <br /> ITRATION p FWLTRT RANCNES AND KENNELS <br /> dER "'L� C MI&CELLANEauS ltltnctl geglst No _ <br /> Color <br /> IDlicaUon pate r —------ <br /> -�.�... BusInQS3rName To Appear On Permit C , <br /> Ype Permi tjeWt @ <br /> u Applicant Name 0. (_0A Address1c C <br /> t <br /> Q x 9 <br /> s Business Teleprlo a No `7 .� Emergent Telephons No <br /> ;orooerty LocatlonrAOdrars F n.� LL � Ter DrSir y <br /> 'Property Owner <br /> 0, <br /> Y <br /> =`" V <br /> �- h — Address S U S <br /> Operators Name C . �� t.6,Address '%I':- <br /> 4.-cls r �—"- <br /> 2� �Tom: =`t r'` I-)u,- 5 r <br /> I FOOD ESTABLISHMENTS Total Building Sci Footage Restaurant Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROAOSIO£FOOD STAND C❑ LIQUOR STORE D BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> 0 VENDING MACHINES/No of ❑ MOSILE FOOD PREP UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No of Field Employees <br /> ALL APPLICANTS Total Employees Including Operators <br /> 2 ROUSING <br /> ❑ HOTELJMOTEL/No of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No of Spacer _ <br /> 3 WATER OUALITY ❑ WATER SAMPLE,Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO OF PUBLIC SERVED(Connections) <br /> 4 RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5 VECTOR CONTROL ❑ POULTRY FARM/Maximum No of Buda <br /> r ENNELJRunways /Animal Population No No of Confining C <br /> ape <br /> Sewage Disposal Method <br /> 0"it'd Wtste Disposal Method - <br /> .ter Supply Source Animal Waste Disposal Method <br /> ❑ CONENLTATION FIM <br /> 7 ❑ PLAN Ct'tIEC1UNG!M <br /> 8 REAL,ESTATE <br /> REQUEST Water Wall Inspection❑ sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tate No <br /> Escrow No <br /> Seller Seiler Address <br /> Telephone No Seller Agent Name <br /> Service Request Fpr Date <br /> I hereby Certify that I haw' pr"NVW this application and that the work will be done in accordance with San Joaquin County <br /> ordinances state lawn, and ru and raqu the San Joaquin Local Health Olt ACL _ e <br /> APPLICANTS SIGNATURE X I +t Data <br /> FOR DEPART11111111EWT USE ONLY <br /> Fee It Due D ANNUALLY Pip UMT D PLR SITE D EAGM ❑ January t a wcmned ft Janlrry 31 ]July t A Raeanwa SY JuW 71 <br /> I <br /> f SILLIII ING AEWTTANMAEYIT DSL IcYih.ANATT� PATE RFAAITT O <br /> I DATE AMOUPrT DUE C?+ECxEC <br /> AMOUNT <br /> FEE "'- <br /> LESS <br /> PRORATION ' <br /> PLUG <br /> PENALTY <br /> OTFIt:R I <br /> OTHER <br /> I <br /> ;Won"pY t3ata Amok"NO PMrNH No Iftim O Oda 1146al4 aa11M71f! <br /> �� A/RICANT�RATtiNN BLL COPMit 70• t1AYHACrN1aMYAl ICttLT11 P[alpTrt;pryl a 11t1 <br /> R.".=TM Aft.00 O.as gate aroMron C.s,CUM <br />