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:. • Appl=sr' He Pr Iced When SubmMNd Completed.Be Sul To Sign The Application. <br /> EN IRONRi E �1.# �11E} "Aifi MSERVICES , 1401- <br /> ENGINEER'S AND/OR �E II�I - . <br /> APPLICANT'S AND/OR. FOOD ESTA11JSM11IENTS,MOUSING <br /> CONTRACTOR AND/OR hOtli.;. �TERSANIPUNG Make <br /> BROKER AND/OR Lic. No. <br /> �NSE AND/OR it+irY itENllFitS <br /> 3TRAT1ON IIRMCEI: wn RegiSt. NO. <br /> 1, ZER - Color <br /> (Application Date 8-!O _ 8 8 Business/Name To Appear On Permit Lob) K 5TAL <br /> oTypePermit/ServiceRequested: FURT!!EQ C#ffCi; OA'J 500- CaAlrAwtVA'lenM _ V_Lusrme TiyMAS � R�ti��sls <br /> Applicant Nang DA I.-to n Bij 7rz_ Address V Q 13 L_o b I CAi- <br /> Business Telephone No. 201-3i4-:2M0Q Emergency Telephone No. SqXe <br /> Property Location/Address -,213 S , 1416-LL Y S7_1 t..-at►i <br /> Property Owner M CS C. A Y j RIC z Address (o I t- M*^. PL.: L-a D J, CAC- <br /> Operator's Name AL G.12asS Address 1412 5AA+7-A YI/6ri 1!IP, 1~all 1. <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Setting Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET-RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOQQ,PRO <br /> 9, ESSING PLANT ❑ COMMISSARY ❑ ICE PLANT 1:1 BAKERY <br /> 1:1ROADSIDE FOOD STAND LIQUOR'SORE 0 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 <br /> 2. HOUS1Nt3 <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces rfl .moi <br /> i 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) 13CHEMICAL Z � Z sL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER ki, O) V j <br /> NO.OF PUBLIC SERVED (Connections) WAIN <br /> 4:'4-RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHIf+ ACJ� �- <br /> POULTRY FARM/Maximum No.of Birds 'VECTOR.CONTROL � C7 <br /> AW:ENNEL/Rwways /Animal Population No. No.of Confining Cages AL <br /> Sewage Disposal Method Q <br /> Solid Waste Disposal Method <br /> Water y Source Animal Waste D Vosal Met <br /> �6 CONSULTATION FEE S t <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: NAIllier Well Inspection❑ Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <br /> Escrow No. <br /> l SelNr,`< Seller Address <br /> Telephone No. Seller Agent Name <br /> Service Request For Date <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑EACH ❑ January 1 3 Received By January 31 ❑ July 1 6 Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER �_ 2 <br /> ived by Date t NO. Permi,lVO. Issuance Date Mailed Delivered <br /> AAPIlCANT—RETURN ALL EMif .^dI'ilEgMtT/5E1Wi '" 'IA04E.Hi42EiTON AYE:,P.Q4 9:001 �TOCIRON,CA 9501 <br /> „w: <br />