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Applications Will Be Pr rssed When Submitted Properly Completed. Be S- To Sign The Application. <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />ENGINEER'S AND/OR <br />APPLICANT'S AND/OR <br />CONTRACTOR AND/OR <br />BROKER AND/OR <br />ic"ENSE AND/OR <br />3TRATION <br />I. .BER <br />FOOD ESTABLISHMENTS, HOUSING <br />PUBLIC POOLS. WATER SAMPLING <br />REAL ESTATE INSPECTIONS <br />POULTRY RANCHES AND KENNELS <br />MISCELLANEOUS SERVICES <br />IF VEHICLE INVOLVED, GIVE <br />Make <br />Lic. No <br />Regist. No <br />Color <br /> <br />[Application Date t/ A , Business/Name To Appear On Permit <br />,Type Permit/Service Requested. <br />.1 Applicant Nagle /910.6727,- 6:-7VVY-Abeie,V7i9?--- Address c7 7M 14t/CV/A., ½//le ,e.- / ,S2,r/ sz,/ .- <br />(2-, T,4-C/1 (4- isY2-7 _ Business Telephone No 6-* ,_.G. (1—El7 2— Emergency Telephone No <br />Property Location/Address 4/4/el/eZ 5". 1/45 /t2C-2 --77- / /17/1'7`a <br />Property Owner g&---cX' de----1/C.,'&14We7V7 Address 2/7 41 ./..)• /47/7/7724,C71- Z/971,C; S- PS2c)7 <br />L OPerator's Name Address <br />1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br />0 RESTAURANT 0 FOOD MARKET RETAIL 0 FOOD MARKET WHOLESALE 0 MEAT MARKET <br />FOOD PROCESSING PLANT 0 COMMISSARY CI ICE PLANT 0 BAKERY <br />ROADSIDE FOOD STAND 0 LIQUOR STORE 0 BAR 0 ITINERANT RESTAURANT <br />CONFECTIONARY STORE 0 FOOD SALVAGER CI FOOD DEMONSTRATION 0 FOOD VENDOR <br />VENDING MACHINES/No. of 0 MOBILE FOOD PREP. UNIT 0 VENDING VEHICLE <br />FOOD CROP HARVESTING/No. of Field Employees 2 ALL APPLICANTS: Total Employees Including Operators < <br />HOUSING -- 55 c - 7.1 no <br />0 HOTEL/MOTEL/No. of Units 0 CERTIFICATE OF OCCUPANCY •-> z -.. :__ 0 MOBILE HOME PARK/No. of Spaces 0 <br />----.1..rr; <br />WATER QUALITY PI 0 WATER SAMPLE (Bacterial) 0 CHEMICAL rri _i <br />PUBLIC WATER SYSTEM 0 SURFACE WATER SUPPLY 0 WATER HAULER <br />NO. OF PUBLIC SERVED (Connections) CT:, rn Z <br />.-.:-... r- <br />rn RECREATIONAL HEALTH 0 SWIMMING POOL 0 SPA 0 WADING POOL 0 NATURAL BATHING PLACE" <br />VECTOR CONTROL 0 POULTRY FARM/Maximum No. of Birds --I <br />I :ENNEL/Runways /Animal Population No No. of Confining Cages = <br />Sewage Disposal Method <br />Solid Waste Disposal Method <br />Water Supply Source Animal Waste Disposal Method <br />3---CONSULTATION FEE (,€)..k Iva,- 7? wer,) Y- ,3-4-0-4/// //U-S12.e(44,2ZR <br />'7 • <br />0 PLAN CHECKING FEE / <br />REAL ESTATE <br />REQUEST: Water Well Inspection:I Sample 0 Title Company <br />Address Tele. No. <br />Seller Address <br />Telephone No. Seller Agent Name <br />Service Request For Date <br />I hereby certify that I ha ,e prepared this application and that the work will be done in accordance with San Joaquin County <br />ordinances, state laws, d rules and regulations of the San Joaquin Local Health District. <br />Sewage System Inspection 0 <br />Escrow No. <br />Seller <br />APPLICANT'S SIGNATURE, <br /> <br />Title <br /> <br />Fee Is Due: 0 ANNUALLY <br />,..- <br />FOR DEPARTMENT USE ONLY <br />0 PER UNIT 0 PER SITE 0 EACH 0 January 1 & Received By January 31 0 July 1 & Received By July 31 <br />BASE EXPLANATION BILLING <br />DATE <br />REMITTANCE <br />DATE <br />$ <br />REMITTED AMOUNT DUE <br />REMIT <br />CHECKED <br />AMOUNT <br />FEE f35 Wevfet <br />LESS <br />PRORATION weraet-- <br />PLUS <br />PENALTY <br />OTHER #.3c•-•:- / <br />0THER <br />0/cf, (6,573 I I'C5 /CA eived by Date Receipt No. Permit No Issuance Date Mailed <br /> <br />CIM/Ints•Aucavr•I LIC A I -rt.. aC011•11./CCOUI,CG gat. C IJA7C11,16.1 AUG IS" 1:1•••• .11,10 a ..... <br />Delivered <br />"AA re cmInt