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- <br /> Appllcatlons Will Be Processed When Submitted Properly ComploNd. By Sure To Sign The Appllcallon. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> BEER 5 ANU Oa If- VEHICLE INVOLVED, GIVE <br /> ,ICANT'S ANDIOR <br /> FOOD ESTARII$HMENT$,fIDU61NG Mahe ___...... <br /> vTRACTOR AND-OR PUDIiC POOL$,WRIER SAMPLING - ------- ___._--__ <br /> COKER ANDiOR NEAT ESTATE INSPECTIONS LIc, No <br /> "'RNSE AND,OR POULIRY RANCHES AND KENNEL$ Regist. No. <br /> 11TRATION MISCELLANEOUS SERVICES <br /> aER Color _ ..- ....._...._.._.._. <br /> ppiicatlon Date__LLt�=$ ____-... Business/Name To Appear On Permit <br /> ype PermiUServics Requested!ted �r __ <br /> pplicant Name�_y tt :t2I ' � +LSJ_JAddress_.._ 1-Z.2 �t]_C�L�. <br /> Business Telephone No......_...._. .... Emergency Tolephone No. <br /> roperty Location/Ad ress.. �5ajal.r.._ 0�5 <br /> repel•ty-©wftec-. _ J... HCl^__._ Address _.. <br /> star-s. e •,T(RC.kf�i1'tP —�J_ ..... .. Address .. .•...-------- <br /> FOOD ESTABLISHMENTS Total 6ullding Sq. Footage Restaurant,Maximum 5onting Cnpnclly <br /> �� ,, •1 >jESTAVRANT ❑ FOOD MARKET RETAIL ® FOOD MARKET WHOLESALE Ci MEAT MARKEh <br /> �--_T'F00f5 PROCESSING PLA�1T`- .CbFAMISSARY__._ ___ -® ICE PLANT --- n BAKFRI' <br /> ROADSIDE FOOD STAND D LIQUOR STORE 13AR 17 111N[nANT n[STALJPANT <br /> I CONFECTIONARY STORE, D FOOD SALVAGER FOOD DEMONSTRATION 0 f-001) VE14DOR <br /> I VENDING MACHINFS/No of`_�_....._ _.__. D MOBILE ROOD f-rtF.P. LINIT ❑ VENOING Vhlil(,i 1-, <br /> FOOD CROP HARVESTING/No.of Field Employees <br /> -L APPLICANTS: Total Employees Including Operators <br /> HOUSING <br /> HOTEL/M01f I,,No of Unita __.__:.._..___ t1 C.L'A i IrICATF(.)F (.)G(;1 WAIU lY <br /> MOBILE HOME PARK/No. of Spaces _......__..._.... . <br /> WATER QUALITY ® WATER SAMPLE (Bacterial) D CHEMICAL <br /> i PUBLIC WAN*14 SYSTEM _- D SURFACE WATGR SUPPLY ❑ WAII'M IIA0LGR <br /> U. OF PUBLIC SERVED(Connections) <br /> RECREATIONAL HEALTH 13 SWIMMING POOL D SPA ❑ WADING POOL Q NA'rURAL BATHING PLACE <br /> VECTOR C:, TROL 13 POULTRY FARM/Maximum No,of Birds <br /> :ENNEL/Runways _ /Animal Population No. —p__— No. of Confining Gages -- <br /> awage Disposal Method .:.. <br /> old Waste Disposal Method <br /> afar Supply Source _ .. _. _-- Anii I West Disposal I�getl}od ---'__-- <br /> ' CONSULTATION FEE `���.S �'V( �P f'Y�t.�.�-` �f'Y1 Ld.('r_► CrJ� <br /> r' <br /> 0 PLAN-C#ECKiNO FEE <br /> REALESTAA; <br /> fL?UEST : Wader WBII Inspaction❑ Sampled Title Company __- .. _. . <br /> Sewage System`lnspecdion ❑ -- <br /> - 'Address_.__ . _ _ -_ — —_-- Talc. No.._. <br /> E=scrow No. .:�..__...—..... .. _ . <br /> Seiler ...---. Seller Address --- <br /> To.l+phone No ....._..-...._--......... Seller Agent Name <br /> Somme Request For Oale __�--••--•__-. <br /> hereby eertily that i have prepared this Gpplioation and that the work will bo done In ac(.0rdaneo with $,in Joaquin (r-unty <br /> ordinances, slate laws, and rules and regulations of the San Joaquin Local Iioelth bislrict. <br /> wl"PLICANT'S %GNATURE X Titio <br /> FOR DEPARTMENT USE ONLY <br /> F@@ is DU@i:L I AN ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Jnnua•y t G Received tit January 31 G Jury I tk nere,"ri t3,t J.jIr?� <br /> BILLING REMITTANCE $ C-IF-re.u.cMr <br /> BASEAMOUNT DI <br /> ' EXPLANATION MED _ <br /> DATE DATE 14CMITTED AlAtrUMI <br /> FEE '..Sf7�(�5�1 r�'.• ,J �f_. '��C/ 1 _— I 10 7;k . Z, <br /> LESS <br /> PNURATIOrd <br /> PLUS f �_' ..-- -• <br /> PENALTY <br /> O'MER �.• <br /> t _ <br /> s .. <br />