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_ t4 1 _ E- r .- I C ,� r . rn Auto <br /> F' • i 2Wili Ba eased When Submitted Properly Compldad.' To Sign The Application. T <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S ANDOR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR $000 ESTABLISHMENTS,NOUSINO Make <br /> CONTRACTOR AND/OR PUBLIC POOLS WATER SAMPLINO <br /> fV(�KER AND/OR REAL ESTATE INSPECTIONS Lic. NO. <br /> ( fSERVICES <br /> --. - <br /> tNSE AND/OR ,��;: POULTNy RANCHES AMO IIENN[[s Regiet. No. — <br /> s - - <br /> jTRATIDN _ MISCELLANEOUS SERVICES <br /> Color ..—s <br /> Application Date. . �� Business/Name To Appear On Permit <br /> w ype Permit/Service <br /> Requested <br /> ppliCantName � _� / Address �j .--�* '¢7«�,G ) %� <br /> �,� B sines Telephone No. Emergency Telephone No. <br /> Foopperty <br /> rfy LocahOn�1Adddrress��,/Q ��IQ=�i�'[ `+�•ry - _-� � �"'i -�"`� - <br /> OwnerS�cLG=.�!J'E.. Address <br /> -LOperator'S Name _ .-- Address - -- --- <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Seating Capacity <br /> ❑ RESTAURANT 0 FOOD MARKET RETAIL 0 FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT 0 COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE 11 BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> 0 VENDING MACHINES/No. of —_. 0 MOBILE F000 PREP. UNIT ❑ VENDING VEHICLE <br /> 0 FOOD CROP HARVESTING/No of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators, <br /> 2. HOUSING <br /> C3HOTELJMOTEL/No. of Units 13 CERTIFICATE OF OCCUPANCY <br /> 0 MOBILE HOME PARK/NO, of Spaces <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL - <br /> 0 PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO, OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL 0 SPA ❑ WADING POOL E7 NATURAL BATHING PLACE <br /> VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds <br /> .ENNEURunways --_ — /Animal Population No. _ No.of Confining Cages—. <br /> Sewage Disposal Method . <br /> Solid Waste Disposal Method <br /> W ter Supply Source _ _ .,_ Animal Waste I)PA to(KT. <br /> 6. CONSULTATION FEET I -�' 1 -" - '� •— - '" -� —--' <br /> L 0 PLAN CHECKING FEE "�T— • <br /> 8. REAL ESTATE OCT 27 1988 <br /> REQUEST: Water Well Inspectiono Sample❑ Title Company - <br /> Sewage System Inspection ❑ Aedres9 —---------- EAETjfw No. <br /> Escrow No. . PERMITISERVICES <br /> Seller .._ Seller Address .-- -- - <br /> Telephone No. Seller Agent Name <br /> Service Request For Date — -- - '- <br /> I hereby certify that I have spar d s application and that the work will be done in accordance with San Joaquin County <br /> �j ordinances, state I I a egu ns o a San Joaquin Local Health District. <br /> J`APPLICANT'$SIGNAT Title4l <br /> Date <br /> I FOR DEPARTMENT USE ONLY <br /> Fee to DUE: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i A R".Clod By January at ❑ Juty I a Received By July 71 <br /> REMIT— <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT_ <br /> v� <br /> rr <br /> FEE <br /> LESS <br /> PRORATION �— -- <br /> PLUS <br /> 1 PENALTY ---�' <br /> OTHER ... <br /> OTHER <br />