Laserfiche WebLink
rE <br /> Appllca*w Wel N� WMn gwbm#led Property CulnPie/ed. M awe *The Apyllcaebr�SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> x""coon APPLICATION IF VEHICLE INVOLVED.GIVEIMke <br /> ACTOR ENVIRONMENTAL HEJLLTH PERMIT/SERVICES Lid. No.A ANdOnI I*M ESTAMM WXM eaValea E ANWpI PMIS PMI&SATES YIIRIeaRequtNoAu TION MAL ESTATE IMPKTMM Color <br /> R_ - ►HATET ILAMM AN 1E11ME11 <br /> MlscQlAMS"Masltta <br /> rApolutlon Dab 11-4-R6 _. BU•inas✓N•rM To Appear On Permk <br /> r �[ <br /> et Type ParmwService Requested: xerox copies Lustre Cal Nameplate Cor p ,_Lodi_,Sa1nRnuin Emu r �/ <br /> CA <br /> ]Applicant Name F oloav and nvirnnmant Is_ AddrOW120 Howard ;t, Suite -4640, ;an Francisco, <br /> d47 _Business Telephone No. Emergency Telephone No. 94105 <br /> Property Location/Address <br /> prop"Owner Address <br /> l Operators N•IDO Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq.Footage Restaurenl MMrknlNn Seatkg Copac" <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> C ROADS*-- FOOD STANC. ❑ LIQUOR STORE ❑ 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 HARVESTIN i/No.of Field Employer" <br /> ALL APPLICANTS: Total ErnP"e Including OPeretore <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEIJNO.Of Unld ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARKRb.Of SPs <br /> 2. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED(Connections) <br /> a. RECIIEAT/OKAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FAR""Imum No.Of Birds <br /> ❑ KENNEL/Rumlreye <br /> /Animal Population No. No.d Confining CagM _ <br /> Sewage Disposal Method <br /> Solid Waste D, vcdsl Method <br /> Web(Supply SourceAnimalWest*Dhposal Method <br /> L ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> T. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> L REAL ESTATE <br /> REQUEST: Wabr Welllnepecoon❑ Sample❑ Title Company <br /> SO."Sysiwn Inspection ❑ Addrssa Tele. No. <br /> Escrow No. <br /> Seller Seller Address — <br /> Telephone No. Seller Agent Name _ _ — <br /> Service Request For Dote __ ----- --- <br /> I hereby canity that I have prepared this appllcalion and that the work will be done in accordance with San Joaquin County <br /> ordinances,state lawn, and mie,,and regulations of the San Joaquin Local Health District.' �,,_/ -_ [ <br /> APPLICANTS SIGNATURE X .�ov-- Title Ir /I:V/,NX/ . Dale �� �/ B• —_ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: O ANNUALLY ❑"R UNIT - ❑ Pen S" Q EAOH ❑ Jew"FY E•R,oH.e,By ArwrY.31 0 hM 1 a n.cw..a By A[I(3 <br /> 1 <br /> 1 REMIT <br /> BASE EXPLANATION BILLING REMITTANCE' / AMOUNT WE U�(,KED <br /> PATE DATE RMT <br /> $1.0_.00_ _—mea_ P EWTTED AYOI <br /> FEE F _VN4 4%E copy-.r quested in- -0-.----- <br /> _ _ -@_$1Q r A G LY r <br /> LESS <br /> PRORATION - -- —. _ - --- <br /> - - -- -- �ET 130PLUS <br /> 9' <br /> PENALTY <br /> -DEC ] 1 86 - CA63-0 <br /> OTNEA 1.40 copies $12.03 <br /> OTHPR ----- -- -HEALTH--- <br /> 35q� PERMITISERVICES <br /> 1AlIC ANT-K(TUYI LLLC AI\\[O (MnaONY(NIAI MIAIIN I[11YIT/ef RVIC[\ 1YIe NAIIlIOM 1V(-In M. alt• •InCKInK.CA New <br />