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Applications Will Be Processed When Submitted Properly Completwd, Be Sure To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SEnviCES <br /> JEER S ANU OR If- VLIIIL:LL INVOLVLO, GIVE <br /> T <br />• .ICAN5 ANDIOR TODD E3TADLISHME418,HDURINI° Mal,e <br /> ';TRACTOR ANO.OR PUOIIC POOLS,WATER SAMPLING <br /> AOKER ANWOR REAL ISTATt INSPECTIONS LIC, NO <br /> ENSE AND,OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Resist <br /> aER Color <br /> hpiicalion Date— -t7—$ —___.. Business/Name To Appear On Permit _.__.___ <br /> ype Permit/Servicesequessted 'Addrespplicant Nameurk-Arhsc <br /> Bulslness Telephone No. Tcfl�•phoro INo. <br /> roperty Location/Ad cess. 5a-M-C' <br /> re#er4y <br /> _ Address <br /> ZsanxaQr- D7RC <br /> _ - <br /> Address .. -- <br /> FOOD ESTABLISHMENTS Total Building Sq. Footage Reotsurant, Maximum Sonting Gripucity <br /> I RESTAURANT ❑ FOOD MARKET RETAIL ® FOOD MARKET WHOLESALE IJ MEAT PAAAKET <br /> i FOOD PROCFSSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ RAKFFRY <br /> ROADSIDE FOOD STAND ❑ LIQUOR STORE D EiAR 11 I flfJr-nh,NT n[STAI PANT <br /> CONFECTIONARY STORE ❑ FOOD SALVAGER CI FOOD DEMONSTRATION 13 FC)OI) VENDOR <br /> VENDING MACHINES/No of _—___._.---_._—_. ❑ MOBILE FOOD PPFf. UNIT ❑ VENDING Vta!I{;t I. <br /> I f'OUD CROP t/ARVESTING/No. of Field Employees --_ <br /> ..L APPLICANTS: Total Employees Including Operators __.... <br /> HOUSING <br /> HOTFL/M01 Ft No of Units ___ -..:_..___ L1 CLR I iriCATF OF <br /> MOBILE HOME PARK/No. of Spaces .._..._.__. <br /> WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHLMICAL <br /> PUBLIC WATFFI SYS-1 EM ❑ SURFACE WAT[R SUPPLY ❑ WA It.H I IAUI_En <br /> J OF PUBLIC SERVED (Connections) <br /> RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL. DATHING PLA(,E <br /> VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> ;ENNEL/Runwaye _ /Animal Population No. --___— No of Confining Cnpiia <br /> -wage Disposal Method <br /> o;Id Waste Disposal Method--- __ <br /> 't'iter Supply Source _ -•- --- Antm1 Wast Dlsp�osai fyjOtt1od <br /> �I j -- t 1 — --- <br /> CONSULTATION FEE C3E%svf �P_-I'Y�.CS ,�E'1 P:I`�fl �—_a_,:l__��Z ��i.� -r !_� F <br /> ❑ PLAN CHECKING PEE --------------__---- <br /> REAL ESTATE <br /> :FOULST Water Well Inspectlon❑ Sample® Title Company . <br /> Sevvage System Inspection ❑ Address <br /> Fscrow No. •- -- — .._ _ <br /> Seller ---. Seller Address --- - - --- — . <br /> Telephone No ....__ __. ._.___. .._ Seller Agent Name <br /> $erv,Ce Request For Dale ---.----_--__-. ------ - __ <br /> I hereby certify that I have prepared this Application and that the work will be dorso in occOrdltnco With San Jc-Tqu!n 4',r I-Inty <br /> ordinances. state laws, and rules and regulations of the Seri Joaquin Local Iinplth blstrict. <br /> 4'i'LICANT'S `,IGNATURE X . ---- -------- ---- -.-. Title - ------ -- _ Petr! <br /> rr <br /> FOR DEPARTMENT USE ONLY I <br /> Fee(4 Due: U ANNI,)ALLY n PER UNIT ❑ PER SITE 0 EACH ❑ January I ° Recaired By January 3I July T rtarnr,yrl <br /> I EASE i EXPLANATION BILLING REMITTANCE S AMOUNT DIJL CItE�"r E0 <br /> I DATE DAIC RLMITT-EL) AMVL"A T' <br /> --------- --- -- - -----.. . . <br /> LESS <br /> PPORATION i .. <br /> PLUS <br /> i <br /> PENALTY <br /> C-HER <br /> , <br /> OTHER I <br />