COMPLIANCE INFO_1985-1993 - Laserfiche WebLink

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ENGINEER'S AND/OR APPLICANT'S AND/OR CONI RACTOR AND/OR BROKER AND/OR .Ir FNSE AND/OR 3TRATiON I. .dER Applications Will B06cessed When Submitted Properly Completed. 0re To Sign The Application. APPLICATION ENVIRONMENTAL HEALTH PERMIT/SERVICES FOOD ESTABLISHMENTS, MOUSING PUBLIC POOLS, WATLN SAMPLING REAL ESTATE INSPECTIONS POULTRY RANCHES AND KENNELS MISCELLANEOUS SERYICkS IF VEHICLE INVOLVED, GIVE Make Lic. No. Regist. No. Color (Application Date i �7� L��ir(►1 uslness/Name To Appear On Permit oType Permit/Service Requested: � � rt1��_�;)e Applicant Name Addr sstZ �_ CT U7 --� `t� - Business Tele one No. `I� r `((p U i r '- ' �I Emerg ncy, Telephone No. _ '�{T�� o Property Location/A I1{ Property Owner'rt �_►_� t' 1 I . P Y ��_ ___ Address -a �� , n.o `Operator's Name _ JYL L 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 /l ❑ HOTlf L/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY r❑ Y9BILE HOME PARK/No. of Spaces 3. WATER DUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER NO. OF PUBLIC SERVED (Connections) 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ 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 S9ply Source ___ Animal Waste Disposal Method 6. 0'''60NSULTATION FEE l' //r." r /w'( 1 Ai . f�L /lr' ! ` r �� ,� i a / ' /, �L 0/1;1, - 7. ❑ PLAN CHECKING FEE -r e. REAL ESTATE REQUEST: Water Well Inspection SampleQ/ Title Company Sewage System inspection% Address Tele. No. Escrow No. Seller _ _, Seller Address Telephone No,,-� Seller Agent Name _ Service Request,F.or Date _. I hereby certify that 'I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, an�f-rules and regylotions of the San Joaquin Local Health District. APPLICANT'S SIGNATURq` X'�:� C� Title r LLn�'��_ _ t]ate'`(/� V - - - - -- --. — . _. FOR DEPARTMENT USE ONLY Fee Is Due: ❑ ANNUALLY ❑_ PER UN_ IT ❑P_ER_SIT_E ❑ EACH ❑_Ja_nuary 1 B Received By January 31 ❑July 1 &Received By July 31 - BASE EXPLANATION BILLING REMITTANCE Z REMIT AMOUNT DUE CHECKED DATE GATE REMITTED — AMOUNT FEE/r kir. __— LESS PRORATION -- PLUS PENALTY OTHER OTHER ilk Received by Date Receipt No Permit No Issuance Date Mailed Delivered - - - - -- --. — . _.