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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> y APPLICATION <br /> r <br /> VIRONMENTAL HEALTH PERMIT/SER CES <br /> ItlNEEIi S ANtiIOR IF VEHICLE INVOLVED,GIVE <br /> Alt 1CAMT'S'ANL7/OR FOOD ESTABLISHMENTS.HOUSING <br /> { CONTRACTOR AND/OR` PUBLIC POOLS WATER SAMPLING <br /> Make <br /> i BROKER ANNOR REAL ESTATE INSPECTIONS LlC. No. <br /> hENSE ANDlOR POULTRT RANCHES AND KENNELS <br /> �TRATION MISCELLANEOUS SERVICES Regist. No. <br /> 1 dER' Color <br /> �Applicallon Date Q Business/Name To Appear On Permit <br /> Typp Pet /Servic squealed: p <br /> Applicant Name' jfe!,111100 110 ''1 1110` <br /> Address <br /> Bust s Telephone No. Emergency Telephone No. <br /> Property Location/A dress< <br /> Property Owner G9 Q <br /> ,.�� Address- <br /> Operators Name' �^L-/���•- to Address <br /> 1 FOOD`ESTABCI$HMENTSx Total Building Sq. Footage Restaurant,Maximum Seating Capacity <br /> 17 ®"RESTAURANTP ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> a �❑°FOOO-'PROCESSING�,PLANT ❑'COMMISSARY' ❑ ICE PLANT ❑ BAKERY <br /> ;.' ®=ROADSIQE`FOOD STANLI= ❑ LIQUOR STORE ❑ BAR <br /> 13 ITINERANT RESTAURANT <br /> 4 ®'CONFECTIONARY,STORE' ❑ FOOD SALVAGER13FOOD DEMONSTRATION 13FOOD VENDOR <br /> s!y ®"VENDING'MAC6ilNES/No.of" ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> k "= ❑""FOOD CROP HARVESTING/NW of Field Employees <br /> ALL APPLICANTS;• Total Employees Including Operators <br /> 'HOTEL/MOTEL/N6.,of"Units' ❑ CERTIFICATE OF OCCUPANCY <br /> E]•MOBIL@ HOME PARK/Na.of Spaces Ad <br /> 3. WATER OUAUTY� ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL 7A1111( <br /> PUBLIC <br /> 1111( 17 2. (1-1 VT <br /> ❑ PUBLIC WATER SYSTEM' ❑ SURFACE WATER SUPPLY ❑ WATER HAULER �^ 7r*V/t <br /> NO.OF PUBLIC`SERVED (Connections) <br /> 4a RECREATIONAL HEALTH^ 13-SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S 5:1? VECTOWCONTROL 13 POULTRY FARM/Maximum No.of Birds <br /> :ENNEL/Runways /Animal Population No. No.of Confining Cages <br /> } Sewage"°Oisposat Method' -- <br /> ! Solid Waste'Disposal Method` <br /> ----------------------- <br /> Water'Supply Source Anim aste Disposal-Metho <br /> 6. �CONSULTATION WE <br /> 7t ❑".PLAN CHECKING FEE <br /> I <br /> W, REAL ESTATEI <br /> REQUEST, Water Well Inspection❑ Sample❑. Title Company <br /> Sewage System Inspection ❑" Address Tele. No. <br /> Escrow No: <br /> Seller, Seiler Address <br /> Telephone No., Seiler Agent Name <br /> Service`Request For Date <br /> I Shereby�certify,`that thave'prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rules"and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE- Title X <br /> Date <br /> FOR DEPARTMENT USE ONLY <br /> dee 1i OUe;❑"!ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July i a Received By July 31 <br /> } <br /> BILLING REMITTANCE E>. BASE' EXPLANATION REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> 1J AMOUNT_ <br /> FEE`' <br /> e LESS" ' ��DO (J•� ! �' I <br /> i <br /> ._ PRORATION` <br /> PLUS <br /> PENALTY f{ <br /> OTMER, <br /> } OTHER �I <br /> Date'' Receipt No. Permit No. Issuance Date Mailed Delivered <br /> ANT—ROTURN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTQN AVE.,P.O.aoa 200 ETQCKTON,CA QST <br />