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Applicatlons Will Be Prj,4sed When Subnpltted property Completed.Be Skwoo Sia the Appnc~,. <br /> APPUCATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICE$ <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED.GIVE <br /> APPLICANT'S ANWOR F�fs3fA#LM1 EMf>L Mi111 Make <br /> CONTRACTOR AND/OR PWt1C I ,.WA-w f wuM6 <br /> BROKER AMD/OR SUL WATE f LIC. No. -- <br /> .IrENSE AND/OR PO.TNf-SANOU ANE ttEMMELS Regist. No. <br /> 3TRATION OwtLLAN""SERVOES I, <br /> I. .GER Color <br /> [Application Date Business/Name To Appear On Permit\ _ A Q IAJG '1 <br /> :Type Permit/Service Requested: <br /> Applicant Name Address <br /> ,..,�.,. Bu nessT_` o e No. I Emergency Telephone-No. <br /> !Property Location/Address t {s�v ~'G" L <br /> 4Property Owner Address <br /> LOperator's Name Address 1 <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIOUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/No.of ❑ MOBILE FOOD PREP. UNIT" a VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. 14OUSOO <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 /> NO.OF PUBLIC SERVED (Connections) i <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL 0 SPA ❑ WADING POOL 13 NATURAL BATHING PLACE <br /> 3. VECTOR CONTROL 13 POULTRY FARM/Maximum No. of Birds <br /> r :ENNEL/Runways /Animal Population No. _ No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source , Ani�^al Waste Disposal Method <br /> i. O QCI4WLTATION IE=EE WA JL <br /> f. O .PLAN OJECKING FEE <br /> S. REAL ESTATE <br /> REOUEST: Water Well Inspection❑ Sample❑ 'Title Company <br /> Sewage System Inspection ❑ Address Tete. No. <br /> Escrow No. <br /> Seiler Seiler 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 rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 6 Received By JilinuilltyZI.. ❑ July/6 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S A UNT DUE CHECKED <br /> �\1 DATE DATE REMI AMOUNT <br /> FEE �� l�V Uv - <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by,, Date Receipt No. Permit No. klquanQO _ lled Delivered <br /> { <br /> t=NWRONIITALHEALTH PERMIT/SERVICES 1b0l 1E <br />