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{ Applications Will Be Pr ed When Submitted Properly Completed. Be So Sign The Application. <br />• APPLICATION Q a <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES ' <br />ENGINEER'S AND OR IF VEHICLE INVOLVED, GIVE <br />APPLICANT'S AND/OR FOOD ESTABLISHMENTS. HOUSING <br />CONTRACTOR AND/OR PUBLIC POOLS. WATER SAMPLING Make <br />BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br />Ir'ENSE AND/OR POULTRY RANCHES AND kENNELS Regist. No. <br />0 3TRATION Unit II MISCELLANEOUS SERVICES g <br />I. .aER --- _ _ Color ---------------._--_--.- <br />-.__._ Business/Name To A .—Ham Laxle 1�l1 1611 <br />Application Date___.____..__.____—___ Appear On Permit __.._�___-____________—._..__ <br />F Type Permit/Service Requested. <br />zC Applicant Name _HaMey _Lane 11C ] 1� .J_ Co. _ __ Address _P ' 0. Box 181G toc on —a - 5201- <br />U----- ----- <br />– ...____ Business Telephone No. Emergency Telephone No. <br />aProperty Location/Address ___Ham— W_ ImiC'- LaT1Cif111 _ <br />P 0. Box X810-Sto��A 952( <br />aProperty Owner _Setl_�O�.tl �m�__.. _.___ _ Address — — , , <br />Operator's Name .—_.____ __— Address _ — <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 ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br />❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br />❑ 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 />❑ 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) <br />4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br />S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds _ _— <br />r :ENNEL/Runways _____—__— /Animal Population No. _—_ No. of Confining Cages <br />Sewage Disposal Method _. <br />Solid Waste Disnosal Method <br />Water Supply Source <br />6. IR CONSULTATION FEE <br />7. ❑ PLAN CHECKING FEE <br />6. REAL ESTATE , <br />REQUEST: Water Well Inspection ❑ Sample ❑ Title Company �l _ <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 a6bordance with San Joaquin County <br />ordinances, state laws. t"(tj' <br />R R„d <br />APPLICANT'S SIGNATURE X <br />Title Date <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & Received By January 31 ❑ July 1 & Received By July 31 <br />BASE <br />EXPLANATION BILLING REMITTANCE <br />$ <br />AMOUNT DUE <br />REMIT <br />CHECKED <br />�i <br />DATE DATE <br />REMITTED <br />AMOUNT <br />FEE <br />$1,537.00 <br />see atta ed 12/28/?0 <br />$1,537.00 <br />_ <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER PENALTIES <br />WI <br />.L BE APPLIED TO PASMUI ACCOUNTS <br />-- <br />-- <br />30— <br />OTHER <br />Received by Date Receipt No Permit No. Issuance Date Mailed Delivered <br />•ww•.n�u: nl�I,wu e• 1 nnw.t� an. l,vlwn�u�e�fa 11 ut�f to wl w6lls.N&naeenrb �6n� B lld4tl gnu E..t Mn w... MM wtnnVenfl ne w1±Mff _- - <br />