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... ..o <br /> APPLICATION._ ,..ti .,,,,,rrka,rvrl. <br /> _ <br /> f ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> AND/OR <br /> IF VEHICLE INVOLV•ED,,GIVE - <br /> r' NT AND/OR FOOD ESTARLISHMENTS,HOUSING - Make <br /> IACT'C A'7C!rlc`A PUBLIC POOLS.WATER SAMPLING .: <br /> aOKER AND/OR REAL E97ATE INSPECTIONS Lic. No. <br /> rFN`'° AND/OR POULTRY RANCHES AND KENNELS <br /> -TION - - MISCELLANEOUS SERVICES Regis/ No: <br /> ` .plplication Date r Business/Name To Appear On Permit' r <br /> ype Permit/Service equested: r C � <br /> licant Name l <br /> ,pP 7 lL6~? �." —/ 'Adiiress F,. <br /> I = _ Business Telephone-No. U y Lf(� �.-�1 SSI: Emergency Telephone No ' <br /> .'roperty Location/Address c � '� Il t �`�LJ�s h�iti.�.- Z),C_ ' ?��� i �•' <br /> 'roperty Owner SPU vie 4&s.`� � �^'4 e- C � _Address -ti w—CU�r� r, F� �'� �+'L f <br /> 1perator's Name I' -Address <br /> I FOOD ESTABLISHMENTS Total Building Sq: Footage Restaurant, Maximum Seating-Capacity <br /> ]''RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE 0-,MEAT MARKET <br /> �IFOOD PROCESSING PLANT ❑ICOMMISSARY 11 ICE PLANT ❑ BAKERY <br /> [ROADSIDE FOOD STAND ❑!;LIQUOR STORE ❑ BAR ❑ ITiNERANT,FIE STAURANT + jI <br /> 7!CONFECTIONARY STORE,- ❑ FOOD SALVAGER 13' FOOD DEMONSTRATION C1FOOD VENDOR I <br /> J'jVENDING MACHINES/No. of l' ❑ MOBILE FOOD PREP. UNIT ❑ VENDING°VEHICLE <br /> �IFOOD CROP HARVESTING/No.of Field Employees. <br /> ICL APPLICANTS:. Total Employees,Encluding Operators V Iiji <br /> C HOUSING I,I <br /> � <br /> 44 ❑ CERTIFICATE OF.OCCUPANCY I <br /> HOTEL/MOTEL/No.of Units.—, - - � � y <br /> �iMOBILE HOME PARK/No. of Spaces 1' <br /> I.E� WATER QUALITY - C1 WATER.SAMPLE (Bacterial) ❑ L <br /> CHEMICA _ <br /> ;PUBLIC WATER SYSTEM ❑.SURFACE WATER SUPPLY ❑ WATER HAULER ( {+ <br /> 10. OF PUBLIC SERVED (Connections,) 11} <br /> I.1p- RECREATIONAL HEALTH 1:1 SWPOOL ❑ SPA ❑ WADING POOL ,.: ❑ NATURAL BATHING PLACE i <br />{ ; `I VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> NEURunways /Animal Population No. No..of Conftning-Cages <br /> SeageDisposal Method I' <br /> solid Waste Disposal Method - <br /> Vater Supply Source Animal Waste Disposil Method i, <br /> 6 © gNSULTATION FEE JL <br /> i t� •PLAN CHECKING FEE O to If) <br /> 4 <br /> i. J.I REAL ESTATE is <br /> :IEQUEST: Water Well Inspection❑1i Sample❑ Title,Company ' <br /> y` Sewage System Inspection . <br /> ❑ Address Tele.'No.•• I <br /> f Escrow No. I , <br /> Seller Seller Address <br /> Telephone No. Seller Agent Name - - <br /> Service Request For Date <br /> ne in accordance with San Joa Vin County" <br /> n that the work <br /> will be do q <br /> ' application and t <br /> re ared this if that I have pp <br /> I I hereby certify prepared <br /> I ordinances, state laws, andsrules and regulations of the San Joaquin Local Health District. <br /> 4PPUCANT'S SIGNATURE k Title Date <br /> FOR DEPARTMENT USE ONLY ' <br /> �h <br /> ' Fee Is Due: ❑ ANNUALLY -C] PER UNIT ❑ PER SITE ❑.EACH - _ ❑ January 1 S Received'By January 31' _ ❑ July 1 A Received By July 71 <br /> _ _ REMIT <br /> BASE EXPLANATION B3LLING 'REMITTANCE S AMOUNT DUE', CHECKED <br /> DATE., DATE REMITTED AMOUNT- <br /> I FEE �� <br /> ,h. LESS <br /> r PRORATION <br /> LUS <br /> 'ENALTY <br /> cf— <br /> Q CJ Cj_ j <br /> If <br /> OTHER �.-�_ <br /> j OTHER <br /> [� <br /> +M <br /> ailed �Deliverad' <br /> usnc Dita - _ <br /> - Permit <br /> No. iia � <br /> Received by -Dale _ E' Receipt N0. - , <br /> " E. P.O.Box 2009 - tiTOCKTOH,C <br /> A 95 <br /> 201 <br /> 4K <br /> AY <br /> w MI 1HLNYICi! <br /> =1101 t.NAiRLT ,- <br /> APPLICANT—RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PiR T ; . L <br /> t. - --._- .- ,{ ..��a�[.�,[i,=[U`�`^�.�_�-�....._�...,.�ii'[r.__�. .._.���__1• N'M�f�____._. ..,r,�n'�V"��^Y�r�V•Y��-^.._��._.-.��__..�t` ,'I- � <br />