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Applicativne Will be Yroc�••ra Wnen buDmlllea Vrc,peuy L utuylalaw. uc sale i u olyn t na ,.yy„�•„�,,. <br /> APPLICATION <br /> ll �-^ ENVIRONMENTAL HEALTH PERMIT/SERVIa w-4 <br /> EN0%NEER's AND/OR - IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR F000 ESTAIUSHMENTS,MOUSING Make _.— <br /> CONT MACTOR ANO/OR PUILIC POOLS,MATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTION$ Lic. NO, . <br /> - NSE ANC/On POULTRY RANCHES AND KENNELS Regist. N0. <br /> 3TRATION MISCELLANEOUS SERVICES g <br /> Color <br /> /vIA`� I� l X88 Business/Name To Appear On Permit ..(�GDFn! EN VI aN�t=NrAL S&RVIC.LS <br /> (Application Date ..— - <br /> .,Type PermiVService Requested:._..RE✓r�� /^IAL �F�!Eoil„ am rzoC_ Fv�.HER Tr�UE LE/✓� ��vOS CAti/NE2Y' <br /> Applicant Name dGn5�/V S✓csAddress PO 9-5)-70 -- 0%ego _CA 7Z/,3P <br /> Business Telephone No.��/")-4SS 3c�45 _ Emergency Telephone No. -"�-• <br /> §__ Averiv� S�-cck nJ Cel <br /> it Property Location/Address �L O•� -50-211 El's ,,c <br /> Property Owner_2lc /eSS o — Address. . <br /> -• -- -•-- <br /> Operator's Name Addres6 -- ---- _ -•-•• <br /> I. FOOD ESTABLISHMENTS L Total Building Sq. Footage Restaurant,Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL 1:1 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 REP.UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators _._.. _ P•( J Fid <br /> 2. HOUSING P C, <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER ME S�R�\c <br /> NO OF PUBLIC SERVED (Connections) <br /> a. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> ` VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> %%... '.ENNEL/Runways /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 /> 6. ❑ CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE --- _ — <br /> a. REAL ESTATE <br /> REOUEST: Water Well Inspection[] Sample❑ Title Company <br /> Sewage System Inspection ❑ Address _ _._..-_ 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 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and <br /> /frules and re\[qu�1g/t)ions of the San Joaquin Local Health District. 1 <br /> APPLICANT'S SIGNATURE x ` "i'i`(7 /C /1 w� _ Title.C�v/NC f �Grtn 4eI Date);Ila _ w/� /v�e� <br /> y <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due; ❑ ANNUALLY []_ PER UNIT-_- ❑ PER SITE ❑ EACH ❑ Jonuviry 1 b Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> [TILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT bUE AMOUNT <br /> CHECKEO <br /> FEE 30 <br /> .. ._ s,O <br /> LESS <br /> PRORATIONPLUS <br /> PENALTY <br /> OTHER <br /> OTHen SQ.�/-1�—r cr ear 99-5 <br /> nectiveo by Date Receipt No. Permit No. lesuance Date Me Cad Delivered <br /> APPLICANT—pfTUAN ALL COPIPR TO- PNVIPn NI./PNTAt 49!AI T4 PR pA1,t,ORp V,!`rq Anc 4�T� rnu Avr e n e_„...,..• .�......�..., �. ..... <br />