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ENGINEER 5+NO.OR iNVIHUNMrfv I AL Mt:AL.I M VtHMi I r JL:HVIL;LS <br /> -- APPLICANTS ANOiOR FOOD ESTABLISHMENT&HOUSING IF VEHICLE INVOLVE[),GIVE <br /> CNTRACTCA A.aO;OR 1•112LM MILL NATER SANFUNS Make <br /> BROKER ANOaOR REAL ESTATE INSPECTIONS i_ic.No <br /> • F-NSE ANOaOR POULTRY RANGNES Ads KENNELS <br /> ,TRATION MISCELLANEOUS SERYICTS RegisT. No. <br /> Color <br /> opiicauon Date BusinessrName To Appear On Permit - r <br /> -• ype Permit/Servlg Reques[rd:_... r ( er-f ' <br /> `Applicant Name 1 La _1ntTte �(LFLAddcess1Cc14c;1 <br /> u rl r. <br /> Business Telephogqe No. `(I?`f�f ZLc_ Emergenc�Telephone No. <br /> iPropertyLocation rAdR f� f•r_' G!' 4 At'th�r�+'�r 4r;rl tr.4:ti�1,nc a' <br /> 'Property Owner �. �� »- Address 0-10 '51a I Lcv,• c i y} -- <br /> _Operator's Name A/ Call4- i'c-f- Address -�•-derma ' .., r- to <br /> 1. FOOD ESTABLISHMENTS Total Building Sq.Footage Restaurant,Maximum Seating Capacity 91 I i <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 /> ❑ 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 <br /> NQ.OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds <br /> r :ENNEUflunways /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> °slid Waste Disposal Method <br /> ,ter Supply Source _- Animal Waste Disposal Method <br /> S. ❑ CONSULTATION FM <br /> 7. ❑ PLAN CHECKING FIE€ <br /> ✓!. REAL ESTATE <br /> _'REQUEST: Water Well Inspection 13 Sample❑ Title Company <br /> Sewage System inspection ❑ Address Tele.No. <br /> Escrow No, <br /> Seller Seller Address <br /> _ Telephone No. Seller Agent Name. <br /> Servtce Request For Oats <br /> 1 hereby certify that 1 htrva prepared Shia application and that the work will he done in accordance with San Joaquin County <br /> ordinances.state lawn,and rules and requisitions of the San Joaquin Local HLmflth District J✓� Q <br /> APPLICANT'S SIGNATURE X it Date ' e 3c43, 0 `O <br /> FOR DEPAATME�r UW OM_Y <br /> FN Is Due:❑ ANNUALLY FM t"T ❑PER SITE ❑EACH 13 SsrKlary i a vw waE aY JvNwV 31 ❑Juty 1 a FAcer ao By JWy 31 <br /> BILLING REtKITTANCE - .B REMIT _ <br /> USE EXPLANATION BATE DATE REMITTED AMOl1NT DUE. CHECXED <br /> AMOUNT - <br /> FEE -- <br /> LESS <br /> - - _ - PRORATION - - <br /> PLUS _ <br /> PENALTY <br /> OTHER _ - <br /> s.. . <br /> X.` -OTHER <br /> Batu by _ Datta _ Rata.pt No. Pannat No. Ipugnp Oats <br /> APKtCAMT-RETUItH ALL COPTES TO:. EWMOt10MMTAL IIBALTH PIRYfT/sa nrNM 101 B_1 AMTOR Aye..P.O,on L14S groc CTOK"A q«.- <br /> - - - <br />