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Applications Will Be Pr seed When Submitted Properly Completed. Be SL^e To Sign The Application. <br /> APPLICATION �/ <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES IF L.a E INVOLVED, GIVE <br /> ENfiMEER:i PNO On FOOYe111L:L� <br /> APP1 DANT'$AND/OR PUB C POOLS,WATER HOUSING Make _ - <br /> CONTRACTOR� PUBLIC POOLS.WATER SAMPLING <br /> REAL INSPECTIONS Lic. No. -- <br /> BROKER AND OR POULTRY RANCHES AND KENNELS <br /> IrFNSE AND OR Regist. No, <br /> 9TRATION MISCELLANEOUS SERVICES Color -- --- <br /> aFR <br /> Business/Name To Appear On Permit <br /> i Application Date - -- <br /> .Type Permit:Servlc Requested' - - - - -- --- - --- - <br /> QAp licanl Name �PaSPA1-�K �N6 �r C w"T Address -- <br /> �'�C� 1.��Bpuusiness Telephone No. . . _ _ - -- Emergency Telephone No ---- ---- <br /> gProperty Location/Address2 (� Qte;v yLA-10D _ _ - ---"--- ----- -- --- <br /> Properly .Il <br /> Owner� t'Q�`��� K%lSltw - _ -.. __ Address - <br /> 1 Operator's Name - -.------ - -- - - Address _- _--- - — —- <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEATINNT <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTCT110t,�o FNDOR <br /> ❑ VENDING MACHINES/No. of - _—_._---____....._- ❑ MOBILE FOOD PVENDINGVEHICLE <br /> ❑ FOOD CROP HARVESTING/No.of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING ppAyMENT <br /> ❑ HOTEL/MOTEL/No of Units __ _ _ ❑ CERTIFICATE OF OCCUPANGYC E V E D <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER SEP 2 9 1988 <br /> NO OF PUBLIC SERVED (Connections) °M��,,�CEiITAL HEALTH <br /> 4. RECREATIONAL HEALTH 11 SWIMMING POOL 11 SPA ❑ WADING POOL ❑ NATURAL BAIFA1INa+wP'ACIF <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds _ PERMIT SERVICES <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 /> 8. REAL ESTATE <br /> REQUEST. Water Well Inspection[] Sample❑ Title Company <br /> Sewage System Inspection ❑ Address _Tele. No. -_ <br /> Escrow No. - <br /> Seller _._ . __._. Seller Address <br /> Telephone No. _ _ Seller Agent Name <br /> Service Request For Date <br /> I hereby certify that I have 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 X _____ -_— _. Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY - -❑ PER UNIT PER SITE ❑ EA CM ❑ January Received 9y January 31 ❑ July 1 A Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT_ <br /> 13 <br /> LESS <br /> PRORATION <br /> Plllfi <br /> PF NAI_TY <br /> OTHER 5Z. ✓`�llt Z 1'I�/ <br /> OTHER <br /> 1 - <br /> necrrrvM <br /> by Dale Pm eml Na Permit No. Issuance Oat, Mailed Delivero0 <br />