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4+ <br /> Applications Will Be Processed When Sut>milied Properly Coal bit Sure To Sign The Appl,eal+oa <br /> ' APPLICATIONENGINEER &',D OR <br /> �'��I�•:-int 1/0� ll.CF� <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> `-nl S Area 3;; FOOD(STAttiswil [S.8OUSIN6 D/ IF VEHICLE INVOLVED,GIVF <br /> CPr.TAACTaR AND Oa PUILIL POOLS.WATER SAMPLING Make <br /> l — ��1 f��NOlrC ��1� <br /> it ori HEAL[STAT[INSPECTIONS <br /> NSE typ;,a POULTRY AANCNES All)lLIc NO <br /> �`Tlor° MISCELLA)l Str VICES Regis[ NI <br /> eel <br /> •AGphCat.on Ca:e -1 �_ 5uslness Name To A 77 e__ Calor r <br /> _ - ppearOnPermrt .)�._... <br /> y.e Fermat Service Requested <br /> uApplicant rsame..� ___.---- ----- --- -�-------- .,.._._-_ �oo•ess .._ - -----�.._ - _.. - <br /> -- - - --_-----..__- Sonnets TelcNnane Np Emergency Telephone r.'o.- <br /> i Property Location Address <br /> r Property Owner <br /> --�-�r=--=...-- Acl3r&ss._. <br /> OPerall Namec,dare5s _ <br /> 1. FOOD E57AE3LiSHMENT5 Totat 5l Sq Footage Restaurant,Maximum Seating Cepaclty _ <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 ❑ IT!NERANT RESTAURANT <br /> C3CONFECTIONARY STORE 1) FOOD SALSALVAGER13FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/No.of ❑ MOBILE FOOD PREP.UNi r ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No of Field Employees <br /> ALL APPLICANTS: Total Employees IncluJing Operators <br /> 2. HOUSING <br /> ❑ HOTELIMOTEL!No.of Units ❑ -FP.!FI °OOC 0 gGY <br /> ❑ MOBILE HOME PARKINo o1 Scaces �SL_Ts c G"•0 <br /> 3. NATER QUALITY ❑ WATER SAMPLE 1BaGtPnal) ❑ CH=MlCAL <br /> ❑ PUBLIC WATER SYSTEr,4 ❑ SURFACE WATER SL Y ❑ WATER HAUL_R <br /> NO,OF PUBLIC SERVED IConneclronsl — <br /> 6, RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WtOINs POOL ❑ NATURAL BATHING PLACE <br /> z VECTOR CONTROL ❑ POULTRY=ARMImaxlmum No-of B l _ <br /> :ENNEL/Runways .,Al Population No. No.of Confining Gages <br /> Sewage OlSposat Mall <br /> Solid Waste Disposal Metnod <br /> water Sup y Source Anunal Wasle paoosai Method <br /> G. ONSULTAT)ON FEE; ;, <br /> 7. ❑ PLAN CHECKING FEE <br /> 8, REAL ESTATE <br /> n=_OUCST; Water Well Inspi m❑ Sample❑ Title Company _ <br /> Sewage System Inspection ❑ AOoress -Tele.No. <br /> Escrow No <br /> Seder -� Seller Aadress <br /> Telephone No Seller Agent Name <br /> Service Rea -s;Fpr Qa:e <br /> I hereby Certify Inst I have Drewa^ed:has ap:�ticahon and Shat the work "i be done-fn actordpre with San Joaquin County <br /> ordinances.stave laws.anp rules and reguiatlo^s of;ne Sar,-Joaquin Loral HE!3a ir Olstl <br /> APPLICANTS SIGNATURE }( - •�r r"{✓ - <br /> �_ �-+ Date <br /> l FOR DEPARTM_NT USE ONLY <br /> Fee Is Duet Cl AN•uA,_, :.t r ❑ ,_ <br /> '-'--�-- �...S__ �E; ❑ J:�.�a•, 'S R .rC�,Manua• 3r <br /> .__ > ❑J�Ir�5 Rster.e:or.Wr 31 <br /> -iOti 5..N� <br /> ^ r --AN-E s REM,' <br /> x'£ _ =-,,A_ ED AMOUNT CVE C•,ctKED <br /> _ LVOUNT <br /> ti; , _..... __ ._..... .. ... ...... ....._.. -_.._ .............. _.._.._.._ _.._.._...... ^.... . __... ..._..___ ._....._... ..._...__ --____ <br /> . - L'.-•. Mn .�-.-..__Lein-1*.c�—_�_---. <br /> Irauance Darr MLrC Dem rr� <br /> -P00CANT-RtTUAN All COP+t$TO ENVIAON&A l NEAl PEAuIT SCAVICES 1601E Na.'CLTON <br /> 17.ea.pM STOW x70 N,CA a3Z0e <br /> f, ,u <br /> IliREPRM=ION THIS <br /> DOGLPM CANNOT BE <br /> INPROVED DUE To IM <br /> CMITIfN OF THE OMINAL <br />