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Applications Will Se Processed When Submitted Property Completed.IN Sure To Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> DrdUIED1111 ARC." APPLICATION IF VEHICLE INVOLVED,GIVE <br /> COWRACT004 AND" ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br /> aROKEA ANDfOR Lid.No. <br /> tJC111181 ANDMA HIM MASU OM&*SUMS Reptat.NO. <br /> REGISTRATION PS"Peels WATER SAMPIIMa <br /> NUMB" SEM ESTATE NOPR:TUM Cold <br /> PWTMl UaCME3 Aes[[MMES <br /> rOCUTA x SEMVAU <br /> rADp�lon Date Businesa/Nerns To Appear On PerRl�t <br /> .Type Permit/Servlos Requested: <br /> Applicant Name 'STD Ta-C, 477 m16Aadraes PaZ �. [ �5 <br /> _Bsiness Telephone NO. u���1 Emaryency Telephone—Tato. <br /> Property Loutlon/AddFw <br /> Property OwltaT 'STDCJ^IDA( Al, AddressEZ-rr <br /> L Operstoes Name f?Alk Address 54d4 ra {, <br /> /. FOOD ESTABUSNMEPCM Total Building Sq. Footage Restaurant.Miudmum Searing CMPscT <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND. ❑ LIOUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD 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 Employees Including Operators <br /> L HOUSING <br /> ❑ HOTELIMOTEIlNO.of Unft ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.Of SPaces <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. RECREATIOPLAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds <br /> ❑ KENNEL/Runways /Animal Population No. No.of Confining Cages <br /> Saws"Disposal Method <br /> Solid Waste Dtaodal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> l ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> T. El PLAN CHECKING FEE 1-(A6T W511 R¢ /N 6/dL' ❑ DANCE PERMIT <br /> e. REAL ESTATE <br /> REQUEST: Water Well Inspection[] SamPle❑ Title Company <br /> Sewage System Inspection ❑ Address ___ _ Tele.No. <br /> Escrow No. <br /> Seita Sailer Address <br /> Telephone No. Seller Agent Name <br /> Service Request For Data <br /> I h Im certdY that I Drepared this application and that the work will be dons in accordance with San Joaquin County <br /> ordinances,stale laws, rules and lations of the San Joaquin Local HealltthrDistrict. <br /> APPLICANTS SIGNATURE X - �3f Lost"` 4 1k OAte <br /> Title <br /> FOR DEPARTMENT USE ONLY <br /> Fes Is Dos:❑.+NATALLY. ❑PER uwT ❑PER 517E' ❑ EACH ❑ Jwwwy I a 9 31 0 x"1 a rleeel.ee BY Ah 31 <br /> REIaT <br /> BASE EXPLANATION BILLING REMITTANCE i Ay0LWT OITE CHECKED <br /> DATE DATE REMITTED AMOLOFT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHEJI - <br /> OTHM <br /> RFcel.edy Deft Retool No. PereM NP. 1Murnq Deft Wtad DHwwW t <br /> AM11C11NT-a[ruNALa.tbaMa TR [NYrpNNpRA/MAITN PatttRinUevrCae len L NAieLTON AVEC PA.e > STOCIRd(u sax" e <br />