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f! <br /> Applications Will Be 1%r essed When Submitted Properly Completed. Be, j To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING IF VEHICLE INVOLVED,GIVE <br /> rONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING Make <br /> ,JOKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> NowirFNSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> I. .8ER Color <br /> Application Date-- Business/Name To Appear On Permit z —CIR'l— 9A4 HiA I M11", <br /> wType Permit/Service Requested'. <br /> z Applicant Name <br /> Address Pb aox Merced , Cl !3S3'�tD <br /> p <br /> Busines Telephone _ Emergency Telephone No. <br /> Property es SC <br /> Location/AAddr � <br /> darp <br /> JProperty Owner CL Address M'I;A <br /> C <br /> 10perator's Name Address Sq r-,t__ <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Seating Capacity <br /> 0 RESTAURANT 0 FOOD MARKET RETAIL C1 FOOD MARKET WHOLESALE 11 MEAT MARKET <br /> 0 FOOD PROCESSING PLANT 0 COMMISSARY 0 ICE PLANT 0 BAKERY <br /> 0 ROADSIDE FOOD STAND 0 LIQUOR STORE 11 BAR 0 ITINERANT RESTAURANT <br /> 0 CONFECTIONARY STORE 0 FOOD SALVAGER 0 FOOD DEMONSTRATION 11 FOOD VENDOR <br /> 0 VENDING MACHINES/No. of 0 MOBILE FOOD PREP. UNIT 11 VENDING VEHICLE <br /> 0 FOOD CROP HARVESTING/No.of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING <br /> 0 HOTEUMOTEL/No. of Units 0 CERTIFICATE OF OCCUPANCY <br /> 13 MOBILE HOME PARK/No.of Spaces <br /> 3. WATER QUALITY 0 WATER SAMPLE(Bacterial) 11 CHEMICAL <br /> 13 PUBLIC,WATER SYSTEM , 0 SURFACE WATER SUPPLY 0 WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH 13 SWIMMING POOL 0 SPA 13 WADING POOL 0 NATURAL BATHING PLACE <br /> %ft.0- VECTOR CONTROL 0 POULTRY FARM/Maximum No. of Birds <br /> r :ENNEURunways —_ /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method— <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> 6. a CONSULTATION FEE 9 <br /> 7. 0 PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST:_- Water Well.I nspection 13 Sample 13 Title Company <br /> Sewage System Inspection 0 Address Tate. No. <br /> Escrow No. - <br /> Seller Seller Address <br /> Telephone No. Seller Agent Name <br /> Service Request For Date <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin County <br /> ordinances,state laws,and les and regulations of the San Joaquin Local Health District. <br /> REX <br /> PPLICANTS SIGNATURE <br /> 4/�/,-j Title Pvpia c e7ev,4/-4/ Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 0 ANNUALLY [I PER UNIT 0 PER SITE 0 EACH 0 January I&Received By January 31O.July I&Received4y,Uuly411* <br /> BILLING REMITTANCE $ CHecHko' Z: <br /> AM6LIj;j�`* <br /> BASE EXPLANATION REMITTED AMOUNT DUE,j, <br /> DATE DATE <br /> 471 <br /> '.FEE <br /> LESS <br /> 'PRORATION <br /> t'77 <br /> W PL LjS_ <br /> 41 PENALTY <br /> Tki R. :4 <br /> TIV� <br />