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Applications WIII Be Pri Bed When Submitted Properly Completed. Be SI —'-o Sign The Application. <br /> / APPLICATION <br /> INCENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> APPIA_ICANt*CANANn/On S AfJD/Un FOOD ESTAOI ISHMENIS,HOUSING IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR III 19 0 PUBLIC POOLS,WAIFR SAMPLING Make <br /> R KER AND/OFT �� REAL FSTATE INSPECTIONS Lic. No. <br /> :NSE ANO/OR POULTRY RANCHFS AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regisl. No. <br /> .dER <br /> Color _ <br /> Ilication Date_G.y __ _._ Business/Name To Appear On Pern it 6evANe 1JT1 -nY,,pe-,.4 .c <br /> I e Permit/Service Requelted:.. rVA 'C. LA..'AS f {��1M[1lJC.l _ t , f <br /> PPllcant Name_ _.11- . -� _ Arlche s G? ��'1_I\.AK�IE� <br /> .-Rr,,�f,�e,,, ,_GI� /_tet-y5. 83BusinessTelephonePJo �y �_0 �.-��i�Emergenc TeleQW i N . <br /> If perty Location Addr�e�ss- ( �Ca j.�SLC�rr �'V1G/N �cC-G q G �.1 <br /> Property Owner ►1 J�s1/Cf r�VGil/�y_f"1 o�i..�:CcT-�s Address 23.E> i. �ya�dl�t t �r J <br /> Operator's Name / - J — — _ ^� J- j ) <br /> W1 G.n e— _sl J _ Address 3,33 ,J(/�M C""Okt VG' f• /1- 1 <br /> I FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> y1 <br /> RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET-WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLAN 1- ❑ BAKERY <br /> IOADSIOE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> DONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FC)OD DEMONSTRATION ❑ FOOD VENDOR <br /> IJ VENDING MACHINES/No. of . ..__.-_____.__... ._. ._.__ ❑ MOBILE f OOD I'IIEP. UNIT ❑ VENDING VEHICLE <br /> C1 FOOD CROP HARVESTING/No. of Field Employees _-_____.__.._ ..... ....._ _. <br /> / -APPLICANTS: Total Employees Including Operators <br /> L. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> (- MOBILE HOME PARK/No. of Spaces <br /> WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> 1' OF PUBLIC SERVED (Connections) <br /> i RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> .ENNEL/Runways /Animal Population No. -_- -__ No.of Confining Cages <br /> nage Disposal Method <br /> id Waste Disposal Method <br /> Water Supply Source ----.. -_ Animal Waste Disposal Method <br /> CONSULTATION FEE <br /> ❑ PLAN CHECKING FEE ------ <br /> 8. REAL ESTATE <br /> RPOUEST: Water Well Inspection[] Sample[] Tille Company _ <br /> Sewage System Inspection ❑ Address <br /> Escrow No. -_ - - ------- <br /> Seller__ . - Seller Address <br /> Telephone No.. . -_.-------_--_-- Seller Agent Name --___-- <br /> Service Request For Date <br /> hereby certify that I have prepared this application and that the work will be clone in accordance with San Joaquin County <br /> ordinances,stale laws,and <br /> ,�rules and regulations of the Sart Joaquin Local Health District. 1y�/,�► Q�p <br /> APPLICANT'S SIGNATURE X %�,/✓ /- . Title <br /> FOR DE ARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE —❑ EACH —_❑ January I d Received By January 31 ❑ July 1 A Received By July 31 <br /> REMIT <br /> BASE EXPLANATION nDAIZEE DATE <br /> JCE nE f AMOUNT DUE CHECKED <br /> —__--- - DAAZE REMITTED AMOUNT_ <br /> FEE <br /> LESS --- --- -- — —--- — <br /> PIiORATI—ON <br /> PLUS — <br /> PENALTY <br /> O1HEn <br />