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Appllcetlona Wa 6. Keeeed Wne� SVOtn hi Property Competed. M Sr. to Sign TM Appga.aUwr. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> OhOISI�SArOrOR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> CONTRACTOR AND/011 ENVIRONMENTAL HEALTH PERMIT/SERVICES Molle -- <br /> GROKMANOMP Lid. No <br /> LICENSE ANOMM Pees MAKMOOrM Ilstlal" <br /> 11EONTRATION MILIC PaNATO YRFUM faegal No <br /> eLL _ <br /> NLRAS" MAL MATE IWECTME Color -_------ <br /> PMILTKf esI1C11 ,AN KERNEL <br /> NIaCDLAR111=ssaelCO <br /> rAPWication Dale _. _. BusmeWName To Appear On Permit <br /> Type Pwinit/Service Requested: —_— <br /> Applicant Name ___ Address _ <br /> _ <br /> Business Telephone No. _ Emergency Telephone No. <br /> uu <br /> Property LOtion/Acidre �.C7 b r' ( <br /> 3 zcr-CJIX- ' (1�� <br /> 4prop"Owner Address <br /> I Operator's Name _ Address _ - <br /> 1. FOOD ESTABLISHMENTS Total Building Sq, Footage Restaurant.Maximum Sooting 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 /> ❑ 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 Operator - <br /> i HOUSING <br /> ❑ HOTEL/MOTEL/No.of Units ❑ 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. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds <br /> ❑ KENNEL/Runwaye /Animal Population No. No.of Confining Capes <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> A. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> T. ❑ PUN CHECKING FEE ❑ DANCE PERMIT <br /> L REAL ESTATE <br /> REQUEST: Water WNI Inpeclbn❑ 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 herby certify that I lave prepared this application and that the work will be done in accordance with San Joaquin County <br /> wdinances. state lawn,and rubs and regulations of ON San Joaquin Local Health District. <br /> APPLICANTS SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee H Due: ❑ ANNUKLT ❑PER LENTr O PER SITE ❑ EACH ❑ JsraerY I a RecNwe ey Jrwwy TI ❑Jut'I a R�et Jury]I <br /> REMrT <br /> BILL111G REMITTANCE 4 <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE PATE REMITTED AMOIMI <br /> FEE <br /> LESS <br /> PRORATION <br /> PLus <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ReCenree try DIN Rece•PI No P.—I No I...poo Waed DMirwtl <br /> AIPLKAM-At1WMlILCOYIa fQ l NINErRK HEALIN PenNIT/al11VIC[a Sart E.HA MATE-FA 4t f0Y gyoC dE[a PMet <br />