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ENGINEER'S AND/OR APPLICANT'S AND/OR CONTRACTOR AND/OR BROKER AND/OR .Ir'ENSE AND/OR 3TRATION I. ZER Applications Will Be P*d When Submitted Properly Completed. Beo Sign The Application. APPLICATION ENVIRONMENTAL HEALTH PERMIT/SERVIC S [Application Date L -?Q- 08 Business/Name To Appear On Permit SE�10►�5 r-NL-Iu tNvy ISL. u)Type Permit/Service Requested: (A &5r TA'O K 2efAiIZ c Applicant Name 5e�'-Ioos aaL luce-1 0G—� t�1C Address 19 -C)19 -C)/ mo P CA 922.1-5 Business Telephone No.t/4_)�461'ZZ7'_5? Telephone No( 2"48' 7 IL Property Location/Address �� 1 a Property Owner W 12. sT t4Q�� Address `.52 \i . LzLL)FLL.. Ave '-Ti *cy -Operator's Name Address 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE ❑ FOOD CROP HARVESTING/No. of Field Employees ALL APPLICANTS: Total Employees Including Operators 2. HOUSING Wr ❑HOTEL/MOTEL/NO. Of Units ❑ CERTIFICATE OF OCCUPANC �, Li a •a jo ❑ MOBILE HOME PARK/No. of Spaces ai t — �i 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) C1 CHEMICAL ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER FEB li NO. OF PUBLIC SERVED (Connections) 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATH ING[MV(i�jMLNJAL HEALTH 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds PERMIT/SERVICES r :ENNEL/Runways Sewage Disposal Method Solid Waste Disposal Method Water Supply Source 6. CONSULTATION FEE 7. ❑ PLAN CHECKING FEE 8. REAL ESTATE /Animal Population No REQUEST: Water Well Inspection Sample❑ Title Company Sewage System Inspection ❑ Address Escrow No. Seller Telephone No. Service Request For Date Seller Address Seller Agent Name _ No. of Confining Cages mal Waste I hereby certify that I have prepared this application and that the work will be done i" ordinances, state laws, and ru les and r gulations of the San Joaquin Local Health District. C Title Of f ice t with FOR DEPARTMENT USE ONLY IF VEHICLE INVOLVED, GIVE FOOD ESTABLISHMENTS, HOUSING Make PUBLIC POOLS, WATER SAMPLING REAL ESTATE INSPECTIONS Lic. No. POULTRY RANCHES AND KENNELS Regist. No. MISCELLANEOUS SERVICES BASE EXPLANATION Color [Application Date L -?Q- 08 Business/Name To Appear On Permit SE�10►�5 r-NL-Iu tNvy ISL. u)Type Permit/Service Requested: (A &5r TA'O K 2efAiIZ c Applicant Name 5e�'-Ioos aaL luce-1 0G—� t�1C Address 19 -C)19 -C)/ mo P CA 922.1-5 Business Telephone No.t/4_)�461'ZZ7'_5? Telephone No( 2"48' 7 IL Property Location/Address �� 1 a Property Owner W 12. sT t4Q�� Address `.52 \i . LzLL)FLL.. Ave '-Ti *cy -Operator's Name Address 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE ❑ FOOD CROP HARVESTING/No. of Field Employees ALL APPLICANTS: Total Employees Including Operators 2. HOUSING Wr ❑HOTEL/MOTEL/NO. Of Units ❑ CERTIFICATE OF OCCUPANC �, Li a •a jo ❑ MOBILE HOME PARK/No. of Spaces ai t — �i 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) C1 CHEMICAL ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER FEB li NO. OF PUBLIC SERVED (Connections) 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATH ING[MV(i�jMLNJAL HEALTH 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds PERMIT/SERVICES r :ENNEL/Runways Sewage Disposal Method Solid Waste Disposal Method Water Supply Source 6. CONSULTATION FEE 7. ❑ PLAN CHECKING FEE 8. REAL ESTATE /Animal Population No REQUEST: Water Well Inspection Sample❑ Title Company Sewage System Inspection ❑ Address Escrow No. Seller Telephone No. Service Request For Date Seller Address Seller Agent Name _ No. of Confining Cages mal Waste I hereby certify that I have prepared this application and that the work will be done i" ordinances, state laws, and ru les and r gulations of the San Joaquin Local Health District. C Title Of f ice t with FOR DEPARTMENT USE ONLY Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & Received By January 31 ❑ July 1 & Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT � � FEE-:—� LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH vEHM1I /SEHVIGW 1601 E. n.a —., �.�