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Applications Will Be r""cessed When Submitted Properly Completed. Be, <br /> ire To Sign The Application. <br /> APPLICATION �7 <br /> TAL HEATH PERMIT/SERWCES It <br /> ENGINEER'S AND/OR ENVIRONMENL <br /> APPLICANT S AND/OR I <br /> CONTRACTOR AND/OR F000 ESTABLISHAILTS.HOUSING IF VEHICLE INVOLVED,GIVE <br /> BROKER AND/OR PUBLIC POOLS.WATER SAMPLING Make ml <br /> ICENSE AND/OR " -• _ REAL ESTATE INSPECTIONS <br /> 3TRATION POULTRY RANCHES AND KENNELS Lie. No. <br /> I. aER MISCELLANEOUS SERVICES Regist. No. <br /> I{{{ Color it <br /> rApplication Date ] Business/Name T �I 'he Beverage Source Inc. J <br /> r Assessment Re1'JOrt Pearfn er(�nnit <br /> F ype Permit/Service Requested: , SUrYace n roear_ n <br /> U Applicant Name— -he � �e �€ Address 490 Second St. San l Francisco, C�! 94107 <br /> I Business Telephone No.14 15) 541-9463 p -887-1132 <br /> `a Property Location/Address�_c, + •ry1 nA_, 7nrai (,p (I EmergencyTele hone.No.(707) <br /> Property Owner <br /> a — leeT.araG`nr[�a <br /> i <br /> -Operator's Name <br /> Address 490 Second St. San :Yancisco, CA <br /> _�_nt+ S+nnpr ' - , <br /> 1. FOOD ESTABLISHMENTS Address 490 Second St. San rrancisco, CA. <br /> ❑ RESTAURANT ❑ Total Building Sq. Footage �� Restaurant, Maximum Seating Capacity ri <br /> FOOD MARKET RETAIL ❑ FOODMARKET WHOLESALE ❑ MEAT MARKET x� <br /> FOOD PROCESSING PLANT ❑ COMMISSARY 0 PLANT <br /> ElROADSIDE FOOD STAND 13LIQUOR STORE ElBp R iI ❑ BAKERY - li <br /> ❑ ERANT RES <br /> CONFECTIONARY STORE ❑ FOOD SALVAGER 11FOOD(DEMONSTRATION 11FOOD VENDOR TAURANT!' <br /> El VENDING <br /> VENDING MACHINES/No. of ! <br /> MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE !� <br /> 11 FOOD CROP HARVESTING/No. of Field Employees 11 <br /> ALL APPLICANTS: Total Employees Including Operators None it IJ <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units <br /> 4 <br /> 11 .xs <br /> MOBILE HOME-PARK/No. of Spaces <br /> ❑ CERTIFICATE OF OCCUPANCY- 1!r <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> 11 PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ ' <br /> WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL El SPA ❑ WADING POOL 11 NATURAL BATHING PLACE v <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds ii I. <br /> F :ENNEL/Runways /Animal Population No. it <br /> Sewage Disposal Method No. of Confining Cages <br /> i u€ ., <br /> Solid Waste Disposal Method !E., 0 <br /> Water Supply Source Animal Waste Disposal Method I <br /> 6. M CONSULTATION FEE �! <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE `{ <br /> REQUEST: Water Well Inspection Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tele. No. it I! <br /> e <br /> Escrow No. E'E <br /> Seller Seller Address II. - 4 '•I <br /> Telephone No. Seller Agent Name <br /> Service Request For Date <br /> I hereby certify that I 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 JoaquinlJLocal Health District. <br /> _ 1 <br /> APPLICANT'S SIGNATURE X � "�I� i� Title fG�rvll a Dater � ~,=r. <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EA GH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ . REMIT et ' <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNTDUE CHECKED <br /> !AMOUNT( <br /> FEE J <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I <br /> eived by ' Date Receipt No. Permit No. IJ Issuance Date Mailed Delivered LI <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES i! 1601/E.HAZELTON AVE.,.P.O.Boa 2009 $TOCKTON,CA 99201 <br /> , � r r, <br />