Laserfiche WebLink
APPS WNI 11111*pry sl Nhd PrepedCotgphi seS( �o sign The Application. <br /> v <br /> APPLICATION.. v <br /> ENVIRClNMMTAL"RALTH PERMIT/SERVICES <br /> BfIt3 AND/OR IF VEHICLE INVOLVED,GIVE <br /> APPLICAM'a ANWOR Make <br /> CONTRACTOR A1NO/OR PWtIC ro"WAM iAN1PUNe <br /> BROKER AN VOR UK UTATti ovemu i Lic. No. <br /> .WENSE AND/OR PwM WIMN ANA ItIMMS Regist. No. <br /> 3TRAT10N MUNaLAMUN 801 <br /> I. ZER Color <br /> (Application Date BusinesatName To Appear On Permit <br /> Type Permit/Service Requested: <br /> Applicant Name Address <br /> Business Telephone No. Emergency Telephone No. <br /> Property Location/Address <br /> Property Owner Address <br /> Operator's Name Address <br /> 1. FOOD Es17 IMENTs Total Sullding Sq.Footage Restaurant,Maximum Seaft Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL. ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ 13AKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION 13 FOOD VENDOR <br /> ;. . <br /> ILL: <br /> VENDIN43 <br /> ALL APPLICANTS: Total Employees Including Operators PAYML�INT <br /> 2. © IVED <br /> ❑ HOTEL/MOTEL/Ii of Units ❑ CERTIFICATE OF OCCAA� <br /> ❑ MOBILE HOME PARK/No.of Spies �+ 11988 <br /> S. WATER allAt.IT1/ 13 WATER SAMPLE(Sectorial) 13 CHEMICAL AUG <br /> ❑ PUBLIC WATERSYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER � T H <br /> NO.OF PUBLIC SERVED(Connectional C� <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BA <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maxlmum No,of Birds T <br /> r .ENNEL/Runwaya /Anima#Population No. 1+f o.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal WailtR: isposal Method <br /> B. ❑ CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE <br /> II. REAL Etl<T'ATt# <br /> REQUEST: Waw WeH Inspection❑ Sample❑ Title Company <br /> Sewage System Inapt oli ❑ Address Tsle. No. <br /> Escrow No. <br /> Seller Seller Address <br /> I9 Acerlt Nis <br /> - -_ <br /> I herelity certify that I haw prepared thl&,opplloation and that the work will be done In accordance with San Joaquin County <br /> ordinances,Mate laws.and ruled and re"Illons of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X Title , Date <br /> FOR[DEPARTMENT UN ONLY <br /> Fee Is Dut:Q ANNUALLY 13 PER UNIT ❑ PER SITE CI EACH Q 1 s ReeNwd By jw4wy 31 ❑ July 1!REwived By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> i <br /> I <br /> Received by DEb ReceW No. Permit No. NOWAM 000 Mlt"d Delivered <br /> APPLICAMT—RLTURN ALL COPlae TO 91104001`11111"1 f f RriCai tM1 E lO tlelll Aye.,P O.On 100E sTeCKTON CA 91111111111, <br /> - <br />