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Applications Will8. Procasaad When Bubmlttad propady ComplalPd. So Sura To Sign The Appllcatlon, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEEAs wNO/Ow <br /> APPLIGIRn{wro;OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> coNTRACTOR AND/DR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br /> eROREII AMLVOR -- <br /> LIGENSE AND10A Fele ESTASLIs11nUff&WJZM Lid. No. <br /> REGISTMTION PUal1C Pssll Issue ssMREN Regist. No. <br /> MIMBEA .. _ HEAL ESTATE"MPELTEest Color <br /> POULTIT RAWNES Ales AEaxuj; <br /> S` MISCELIAKEKM ssa ElRa <br /> Application Date Business/Name To Appear On Permit �j /A , r <br /> .Type PermlVServiceRested: �� / <br /> Applicant Name �2/E>(� �G � Address <br /> Bu ries Telepn ne No. �3L—L{I�I Emergency Teleph na No. <br /> (Property Location/Addreas Z <br /> IProoarty ow" Addre.. <br /> I Operator's Name Address -J lr0 4 r <br /> 1. FOOD ESTABLISHMENTS Total Building SQ. Footage Restaurant M"Jmum SMting Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PUNT ❑ 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 /> 2 HOUSING <br /> ❑ HOTEL/MOTEL/No.Of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces <br /> 7. WATER OUALITY ❑ 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 /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds <br /> ❑ KE:NNEL/Rur ways /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 /> C ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> T. ®.PLAN CHECKING FEE /-L/� ❑ DANCE PERMIT <br /> S. REAL ESTATE <br /> REQUEST: Water Wall Inspection❑ Semple❑ Title Company <br /> Sawn*System Inspection ❑ Addrpa <br /> Teal.No. <br /> Escrow No. . <br /> Seller Seller Address <br /> Teeephons No. Seller Agent Name <br /> Service Request For Date <br /> I hereby certify that 1 have prepared this application and that the work will be done In accordance with San Joaquin County <br /> ordinances,state lawn,and rules and regulations cel the San Joaquin Local Health District. <br /> APPLICANTS SIGNATURE X C(/--E/ Title -C / vl. Date S D—6- <br /> FOR <br /> _ZZ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is DIM:❑-ANNUALLY ❑PER UNIT ❑ PER&TE ❑EACH ❑ Jwywy 1•REeslsaa tay.IwrNy_al ❑,AA,1 l Asuwsa or Ray 31 <br /> eASF EXPLANATION BALING REMITTANCE $ REAATii <br /> DATE DATE REMITTED AM uih r DISE CHECKED <br /> AMOI MT <br /> FEE <br /> LESS 6 <br /> PRORATIOII <br /> PL W <br /> PENALTY <br /> OTHER <br /> OTHER <br /> A�by dM Rau,p Na Pw No IMuar,ra Dant WYAe paK,.w,b <br /> APPLICANT—RITIIW AIl.(dKal TQ fMYIapMYEM1LL HaA "P[RMITMEAYN:Ell IratC HAIELT(MIA <br /> Y�PA.ter 700E ROO[TOIE G Y>A Y <br />