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VF . 0,Applic. lons WIII B.PAL When Submlued Property Completed. B. Sureig. Th. ApPllcatl0<� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> UIGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> .WPLI['hM'$ANOIOR <br /> CONTRACTOR AND/GR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br /> BROKER AND/OR Lid. No. <br /> LICENSE ANDr0r1 FOOD ESTABLISHMENTS,HOUSING Regist. No <br /> A . <br /> REGISTRTION PUBLIC POOIA.MATES SAMPLING -- <br /> NUMBER REAL ESTATE INiPEC110111 Color <br /> POULTAT RANCHES AND KENNELS <br /> NISCELIANEOUS SERVICES I <br /> =%C7(�eS?Z� C�Yn ✓Pl <br /> (Application Date , % I ��- Business1/�Name To Appear On Perm <br /> I..Type PermiVService Requested: �Cri.1a-�"ODS - �1 <br /> Applicant Name " '" ��cl,N �' a Address '�r 17IIy1P�1{_,�C <br /> _Business Telephone No.�)LICI- -IL]ZS Emergency Telephone No, <br /> Property Location/Address -748 S Unic,' 1 Vii. StG< K'fi-1l <br /> iProperty OwnerTllehkhl�f1, ]Zl �anbl! Fe ,Gu/uY_u Address �/ - o��.�Pl/' %� /j <br /> L Operator's Name Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant.Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFEC fIUNART S FUSE ❑ FOOD SALVAGER ❑ FUOU DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP.UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No.of Field Employees <br /> ALL APPLICANTS: Total Employeea Including Operators <br /> i HOUSING <br /> ❑ HOTEt/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spec" <br /> 1 WATER QUALITY ❑ WATER SAMPLE(Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO.OF PUBLIC SERVED (Connections) <br /> A. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds - <br /> ❑ KENNELfRunwaya /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 /> L -© CONSULTATION FEE Z v�`� BUSINESS LICENSE <br /> 7. ❑ PUN CHECKING FEE ❑ DANCE PERMIT <br /> L REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Semple 13 TitleCompany <br /> Sewage System Inspection ❑ Address Tole. No. <br /> Escrow No. <br /> Seller_ Seller Address_ <br /> Telephone No. Seller Agent Noma <br /> Service Request For Date <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state Ia , <br /> T' and rules and regulations of the San Joaquin Local Health District ` <br /> APPLICANTSIGNATURE X -� � F I� I �, tl I E Titlel- /' Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IN DUN: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ JNnuary 1 A Raceme BY J. ,Ji ❑ July 1 A Recenoe By Jule 31 <br /> BILLING REMITTANCE f REMIT <br /> BASE E%PIANATION AMOUNT WE CHECKED <br /> DATE [ DATE �yPREMITTED AMOUNT�� <br /> FEE - i - (e\� G6 lei OQ <br /> LESS <br /> MORA71ON <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Q ---y 7 <br /> Rec mW by al. R. .w N.. Pemul No — tuwnu D.T wiM 13*1 e <br /> AMICAIR–RC1LaHALL COIIEYTQ. EAynA0NMENTAL HEALTH PERNITnARV10EA uOI f.N fLTON AVL,P.O.b.IDM STOC1 M CANaae1 <br />