Laserfiche WebLink
.a <br /> b <br /> �.e <br /> Application+Will Be P^'e6Aed When Submitted Properly Completed Be 5-ire To Sign The Ayplicshon. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT;SERVICES <br /> IF VEHICLE INVOLVED.GIVE <br /> E•.S%-.Ems 4'iC " <br /> (000 ESTAatlSHM[HiS.MOUSING make .�. -�---__�- <br /> ^4GrV� PUILIC FOOLS.WATER SLMPLING — <br /> ,r-�yE^ANC� REAL[STATE INSPECIIONS LIC NO <br /> POULTRY RANCHES ANO RENkELS Reglst No - ---- <br /> �Tr.ATiD!r PUSCELEANEOUS SERYICES <br /> Color <br /> eER <br /> AGpIICaLcn�.a'9. _ .. ----.. BjSIn?55'Name ID paea! On Perr-.: <br /> o7ype Perm-1 Se'vlce Rect;e$lec - <br /> -� Adrress •__J <br /> Z.ApphcantName -- <br /> '? -y-- --- _-- Business Telephone No —s _ __------ -- Emergency Telephone No —.- <br /> - -- <br /> �Property location Aesress. r----�- ------- <br /> J Property Owner �.�— -- — f - .— =--=-- Aearess <br /> 4 _ - <br /> ; <br /> Operator s Name- A=re--s5 <br /> 1. FOOD ESTABLISHMENTS Total Buiiding Sq Footage Restaurant,Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET tvrtOLESALE, ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIOUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOL'DEMONSTRATION ❑ FOOD VENDOR <br /> (3 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 /> 1) HOTELIMOTEI_INo.of Units El 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 ❑ `NATER HAULER <br /> NO.OF PUBLIC SERVED(Connections)_ <br /> .4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA D 14ADING 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 Sup Source Animal Waste Disposal Method -- <br /> g, ONSULTATIOS FEE <br /> T. ❑ PLAN CHECKING FEE <br /> S. REAL ESTATE <br /> REQUEST: Water Well Inspection© SampleD 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 I have prepared this application and that the work will be done in accordance with San JUPquln County <br /> ordinances,state laws,and rut and regulocins of the Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> Title Date <br /> / FOR DEPARTMENT USE ONLY <br /> Fee Is Due:I3 ANNUALLY Ly/A UNIT ❑ PER SITE ❑ EACH L.7 January l&Recelred By tanuary 31 0 July A Receiv*4 BY Juiy 31 <br /> - I RE611T <br /> 945E 9 EXPLANATION BRLING I REMITTANCE - S AMOUNT RUE GH ECKED <br /> DATE III DATE REMITTED AMOUNT <br /> FEE r .. <br /> LES5 <br /> PRORAT I DN <br /> .. _ PLUS <br /> PENAL7r 1 <br /> �. ,=�--- Issuance pale uan.e D.Ir.er.a <br /> RS 41 Cale R!LlIP7 NO Pt•md NG <br /> AIP0LICAHT RETURN ALL COPIEA TD: EHVIROH7/EHTAL HEALTH PERY1TrtiERYIC ES 1641 E.HAIELTON AVE„P.O.l]44e aloCaloH.CA <br /> eE MION OF THAs <br /> DOCUMW. CANNOT BE <br /> IMPROVED DM TO TW- <br /> CONDITION AUT' T-W— ORIGINAL <br />