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J1 Ell <br /> APPLICATION <br /> ONVINOWINTAL HEALTH PH"IMtT SPIRWCE6 <br /> F0401Nfs1}l'a ANDOM rob 13TA1011AMIMTa,1i40H1itG IF VEHICLE INVOLVED,GIVE <br /> AFPLIeANY71 ANb,bri Pultic I�AOtil.111111110Pprdruoc <br /> CONTRACTOR Asit�,oH <br /> DROKCR ANWOR ptkt[AraiI INIPICtIONA LIC.ND..._...__..._.......� <br /> 'VSE ANDiOR POULTRY 01110Hta ANO N111.41L1• <br /> TRyTrgN Sils iLLAVEDeR solmoIs, Gol <br /> fApplicatiori Date - 9 ___ .. Business%Njme To Appear On crmdy-•----- <br /> oType Permit/Service Requested;------------•--- <br /> Applicant Name _ _ ... Address..�ay.(�.•:�cinr�S.1L743hL4]�!F <br /> a�111��f'q fig_-- Business Telephone No..__- ---- . Emergency Telephone Nr. <br /> °%Property Localion/Adndrreess. �0A}��-/�L L�— -•-----.-_-..__ ----- <br /> iPropertyOwnerielty� J --•_ --___.__..__.-_- Adrlrnas_ <br /> 10peralor'sName T _.__.._ Address -----._ _ <br /> 1. F100 ESTABLISHMENTS Total Building Sq.Footage Restaurant,Maximum Seating Capacity <br /> ❑ RILSTAURANT 0 FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT E3COMMISSARY Cy ICE PLANT ❑ BAKERY <br /> © ROADSIDE FOOD STAND 13LIOUOR STORE IJ BAR ❑ ITINERANT RESTAURANT <br /> E3 CONFECTIONARY STORE 13FOOD SALVAGE`i 13FOOD DEMONSTRATION 13FOOD VENDOR <br /> ❑ VENDING MACHINES/No.o1 ❑ MOBILE FOOD PREP.UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No.of Field EmployeesALL APPLICANTS: Total Employees Including Operators -- <br /> 3. HOUSING <br /> ❑ HOTEL/MOTEL/No,of Unite ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARKINo,of Spaces <br /> i' ❑ CHEMICAL <br /> 3. WATER QUALITY ❑ WATER SAMPLE{BacleNaq <br /> ❑ PUBLIC WATER SYSTEM © SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO.OF PUBLIC SERVED{Connections} -- <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL (J SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> F "•"VECTOR CONTROL ❑ POULTRY FARMlMa%Imum No.of Birds- <br /> ..IENNEL/Runways /Animal Population No, No.of Confining Cages- <br /> w'_Sgo Disposal Method ------- <br /> SGA:_Waste Disposal Method — <br /> 3 Water Supply Source -_ _ Animal Vlasic Disposal Method <br /> 5. QNSULTATION FEE <br /> � <br /> 7. ❑ .PLAN CHECKING FEE <br /> a. REAL ESTATE <br /> REOUEST: Water Wall inspection 13 Semplo❑ Title Company <br /> Sewage System inspection ❑ Address Tele,No. <br /> Escrow No, - <br /> Seller Seller Address <br /> Telephone No, Seller Agent Name <br /> E <br /> Service Request For Dale --- -- <br /> i <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,elate laws,and rules and regulations of the San Joaquin Local Health District. <br /> ter.. APPLICANT'S SIGNATURE X Title Date <br /> FOR DENARTMENT USE ONLY <br /> Fee Is DJs:❑_ ANNUALLY ❑ PER UNIT ❑AEH SITE ❑EACH ❑January 1 6 Received BY January 31 ❑July I!L Received BY July 31 <br /> FIFWIT <br /> BASE EXPLANATION BILLING I REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ~ ,O 11/CS. <br /> L>as PE I,AI T'I'c�4rlE.l.F3E F.."^rF��l.I//F�TTDCCT ^�y <br /> PRORATION PLUS J 1"\ VI D1 Llili UAlt. <br /> v \ PENALTY r7—.— <br /> _yQ�{kr OTHER 9 <br /> OVHER <br /> --------------- <br /> eca,ed by ___---Oats Rece-pr No Po m,l No f-�issuance Ds1e Mailed Delivered <br /> 1. _. <br /> APPLICANT—RETURN ALL CUP763'r0: .EIFYIRONl1iENTAL riEALTH PERetITISERyICES 1601 E.HAZFLTON AYE„P,D.9oa?DpY ETOCKTOM,CA SSM <br /> .1 - <br /> r. _ ,/���IL�Ir "IMS q� <br /> TIE <br /> -.�a-a ,PRODUCT <br /> I`4/�.',� OF '?-i d S <br /> IMpRo" T0. - <br /> ITIC�N Vr . TW <br />