COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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Applications Will Be Pr ENGINEER'S AND/OR APPLICANTS ANO/OR CONTRACTOR AND/Of, BROKER AND/Oft kV',ENSE AND/PR =TIONG 03gpV�j QPG�wv. �g .sed When Submitted Property Completed. Be St o Sign The ``000 �P��N p 9 Applicatio �' P - APPLICATION �M�,�4a��C ENVIRONMENTAL HEALTH PERMIT/SERVICES Application Date — Business/Name To A r n ppe� On Perm 't 1 a Type Permit/Service Requested: Applicant Name �A�/��IIAI/ SCIGN�GT11(.FMI IL — Business � s TelephNo. 114LJ Zg-2i - 70') 1 Emergency Telephone No.015T i Property Location/Address 5 a' Y �yocizT m C'A Property Owner0 S --r Address •LOperator's Name 0t Address i�DM1Ll'il� 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE 0 MEAT MARKET ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR 0 ITINERANT RES ❑BAKERY ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR TAURANT ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ ❑ FOOD CROP HARVESTING/No. of Field Employees VENpING VEHICLE ALL APPLICANTS: Total Employees Including Operators nn 2. HOUSING _-_ ArN /61S`.- ❑ HOTEUMOTEL/No. of Units - ❑ CERTIFICATE OF OCCUPANCY ❑ MOBILE HOME PARK/No. of Spaces —_ 3. WATER QUALITY ❑ WATER SAMPLF (Bacterial) ❑ CHEMICAL ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER NO. OF PUBLIC SERVED (Connections) 4. RECREATIONAL HEALTH ❑ SWIMMING PO U SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds r :ENNEL/Runways /Animal Population No. No. of Confining Cages Sewage Disposal Method Solid Waste Disposal Method — — Water Supply Source Animal Waste Disposal Method 6. 11 CONSULTATION FEE 7-4 PLAN CHECKING FEE 8. REAL ESTATE REQUEST: Water Well Inspection 11 Sample ❑ Title Company Sewage System Inspection ❑ Address Escrow No. Tele. No. Seller Address -------------- Telephone No. _- Seller Agent Name ---------- ervice Request For Date -------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules /And remilation I the San Joaquin Local Health District. APPLICANT'S SIGNATURE X Title Date Fee Is Due: ❑ ANNUALLY BASE FEE. (�� LESS PRORATION PLUS PENALTY OTHER FOR DEPARTMENT USE ONLY ❑ PER UNIT ❑ PER SITE -EACH ❑ January 1 6 Received B January ry 31 ❑July 1 6 Received By July 31 EXPLANATION BILLING REMITTANCEREMIT DATE i AMOUNT DUE CHECKED DATE I REMITTED AMOUNT FOOD ESTABLISHMENTS. HOUSING IF VEHICLE INVOLVED, GIVE PUBLIC POOLS. WATER SAMPLING Make REAL ESTATE INSPECTIONS Lic. NO. POULTRY RANCHES AND KENNELS MISCELLANEOUS SERVICES' Regist. No. Color Application Date — Business/Name To A r n ppe� On Perm 't 1 a Type Permit/Service Requested: Applicant Name �A�/��IIAI/ SCIGN�GT11(.FMI IL — Business � s TelephNo. 114LJ Zg-2i - 70') 1 Emergency Telephone No.015T i Property Location/Address 5 a' Y �yocizT m C'A Property Owner0 S --r Address •LOperator's Name 0t Address i�DM1Ll'il� 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE 0 MEAT MARKET ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR 0 ITINERANT RES ❑BAKERY ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR TAURANT ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ ❑ FOOD CROP HARVESTING/No. of Field Employees VENpING VEHICLE ALL APPLICANTS: Total Employees Including Operators nn 2. HOUSING _-_ ArN /61S`.- ❑ HOTEUMOTEL/No. of Units - ❑ CERTIFICATE OF OCCUPANCY ❑ MOBILE HOME PARK/No. of Spaces —_ 3. WATER QUALITY ❑ WATER SAMPLF (Bacterial) ❑ CHEMICAL ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER NO. OF PUBLIC SERVED (Connections) 4. RECREATIONAL HEALTH ❑ SWIMMING PO U SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds r :ENNEL/Runways /Animal Population No. No. of Confining Cages Sewage Disposal Method Solid Waste Disposal Method — — Water Supply Source Animal Waste Disposal Method 6. 11 CONSULTATION FEE 7-4 PLAN CHECKING FEE 8. REAL ESTATE REQUEST: Water Well Inspection 11 Sample ❑ Title Company Sewage System Inspection ❑ Address Escrow No. Tele. No. Seller Address -------------- Telephone No. _- Seller Agent Name ---------- ervice Request For Date -------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules /And remilation I the San Joaquin Local Health District. APPLICANT'S SIGNATURE X Title Date Fee Is Due: ❑ ANNUALLY BASE FEE. (�� LESS PRORATION PLUS PENALTY OTHER FOR DEPARTMENT USE ONLY ❑ PER UNIT ❑ PER SITE -EACH ❑ January 1 6 Received B January ry 31 ❑July 1 6 Received By July 31 EXPLANATION BILLING REMITTANCEREMIT DATE i AMOUNT DUE CHECKED DATE I REMITTED AMOUNT