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_ ww <br /> r uY V <br /> ENOINEER's ANO/OR ENVIRONMENTAL'H PE MIT/8!t _,.. Z'8'"Pr `I <br /> APPLICANT'S AND/OR EDS ESTABUSNMFNT&HOUSING IF VEHICLIC; OLVED.GIVE <br /> CONTRACTOR AND/OR PWLJC P"L&WATER SAMPU" Make <br /> BROKER AND/OR REAL ESTATE INSPECt10NS <br /> Ir FENSE AHD/OR POULTRY RANCNES AND KENNELS LIC. NO. <br /> iTRATION MISCELLANEOUS SENYICEI COO Regist.No. <br /> 1. .aEA Color <br /> f Application Date _ 1-14 $$ Business/Name To A it On Permit <br /> 1 Type Permit/Service Requested PHOTOCOPY- OF_ REC(PI�DS - BEECHNUT AND 11TH ST. TRACY <br /> Applicant Name E. -fb�Hr TRACY, T �'�', BLVD. & BEECHNUT RD. TRACY <br /> RADIAN CURPURATIUN _ Business Telephone No. Emergency Telephone No. <br /> Property Localion/Address ATTEN;. SUSAN�CHEIBET.r 10385 CILD PT A(ERVTT T F RI) SWRAMENT(1 <br /> r <br /> �Property"ner Address <br /> ,[Operator's Name _ _.-..... .. . Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, M"Imum Seating 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 Operators <br /> 2. HOUSING ' <br /> ❑ HOTEUMOTEUNo. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces __- <br /> 7. 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 /> r :ENNEURunways /Animal Population No. __- No-of Confining Cages <br /> — <br /> wage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source _.._.. Animal Waste Disposal Method <br /> 6. 0 CONSULTATION FEE . ____ _ <br /> .._ <br /> PLAN CHECKING FEE ---.. ___-_. _._____-_____ <br /> B. REAL ESTATE - <br /> REQUESTWater Well Inspection Sample❑ Title Company <br /> Sewage System Inspection Adores- _ Tele. No. <br /> Escrow No - - — --- - <br /> Seller . . Seller Address <br /> Telephone No Seller Agent Name <br /> Service Request For Date <br /> I hereby certify that I have prepared this appllcahon and that the work will be done in accordance with San Joaquin County <br /> ordinances. state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X Title <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUM l v ❑ PLII(INII O PI H•,nT ❑ f ACn <br /> II O Jauary ecen . <br /> I a ned 11y JenA ry JI ❑ July I a Received By hrq n <br /> 1 _.._. . .__ ___. REMIT <br /> BASF IWL ANA TITIN HILIING REMITTANCE L - <br /> AMOUNT DUE CHECKED <br /> DATE DATE _ REMITTED AMOUNT <br /> FEE $30.00 @10. REVIEW AND UPY RE U STED INFO <br /> LESS — -- -- — — <br /> PRONATION <br /> PLUS _._-- <br /> PENAUy <br /> OTHER <br /> 9.60 96_CUPIIES 0.10 <br /> o1HE11 ... 2 .40. 1 _POSTAGE 42 .U0 <br /> Rµ'bvya <br /> by pAlt Hr.cl.p,Nn PMmil NO --- INufM'a MM _M8.14. ---TArlrrpM <br />