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08-08-90 03: 18PM FROM TEL QfNG • P09 <br /> Appllcallons Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEERS AND/OR IF VEHICLE INVOLVED,GIVE <br /> APPLICANTA AND/OR FOOD ESTARLIENMENTS, HOUSING Make <br /> CONTRACTOR AND/OR PUSLIO POOLS,WATER SAMPLING - - - <br /> aROKER AND/OR REAL ESTATE INSPECTIONS Uc. No, -.-_.._. __... <br /> .IngNSE AND/OR POULTRY RANCHES AND KENNELS RegiBL No._.,__.... .. . _. <br /> 4TRATION MISCELLANEOUS SERVICES -- <br /> I, .6ER _,4- S.6?SX9 Color ...—_..___..__ . ._-. .... <br /> 0"Ar /gree <br /> Application Dale ...._ Business/Name To Appear On Permit <br /> Type Permit/Service Requested; <br /> —.._._.,..._- -�--..._.--------. ... .. ..-- ----..__.......__. ._._—...,.....-----. .. -- --.._. <br /> Applicant Name _ �.1/4?� �A._f~..s'LAW LCIS!_ Address .//.�- .,- -_,r�ii,tl•r.f�/'l/.,�,,.#��'jF.'- _�j d <br /> Buslness Telephone No. �� ..27 0Emergency/Telephone 1�8� (�►�c <br /> %Property Location/A <br /> J Property Owner <br /> I-�iG.AI" .._ .�♦.��—.. Address Aar �v. <br /> Operator's Name .— Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq; Footne Restaurant. Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL C7 FOOD MARK"HOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANj'— ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/N0. Of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/Nd, of Field Employees -- <br /> ALL APPLICANTS: Total Employees Including Operators _... <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/NO. of Units __ ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/NO. Of Spaces <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds _..^.....W.__ <br /> r :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 /> 6, ❑ CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE <br /> B. REAL ESTATE <br /> RECUE5T. Water Wallinapection❑ Saul Title Company <br /> Sewage System Inspectlon ❑ Address —..— .� _.Tele. No. <br /> Escrow N0. . ....__.,.,_` .__._. <br /> Salter _.__... ._......._...—_—.—.. Seller Address _-- ---. ----- <br /> Telephone No. --_ Seller Agent Name <br /> Service Request For Data <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with Sen Joaquin County <br /> ordinances. state laws, <br /> Co.Eisc+t714il " <br /> APPLICANT'S SIGNATURE X Title Odte _. <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 a Received By July 31 <br /> BILLING REMITTANCE g REMIT <br /> OA$E EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE _— <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER __ •_-�-. ._. _.__ <br /> OTHER -.__--- <br />