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ENGINEER'S AND/OR <br />APPLICANT'S AND/OR <br />CONTRACTOR AND/OR <br />BROKER AND/OR <br />.DENSE AND/OR <br />3TRATION <br />I. .aER <br />Applications Will Be Proce d When Submitted Properly Completed. Be Sure Sign The Application. <br />APPLICATION <br />E RONMENTAI HEALTH PERMIT/SERVICES <br />IF VEHICLE INVOLVED, GIVE <br />KAokn <br />FOOD ESTABLISHMENTS, HOUSING <br />PUBLIC POOLS. WATER SAMPLING <br />REAL ESTATE INSPECTIONS <br />POULTRY RANCHES AND KENNELS <br />MISCELLANEOUS SERVICES' <br />Lic. No. <br />Regist. No. <br />Color <br />[Application Date Business/Name To Appear On P rmit �cL-�r� <br />,Type Permit/Service Requested: Z L / ,—' Z <br /><APPiicant Name KALI-1i " Address <br />aS " Business Telephone No. " '� —1749 ® Emergency Telephone No, <br />A Property Location/Address °7 Z s, "Z P -%!J ' S C—C ,�-' <br /><Property Owner e' V PZ -S Address 8-211 � . iZ GK 1.1-? G%f <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 PAYMENT <br />® MOBILE HOME PARK/No. of Spaces RECEIVED <br />3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br />❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER J U L 27 1988 <br />NO. OF PUBLIC SERVED (Connections) <br />a. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATH IN NMENTAL HEALTH <br />S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds PERMIT/SERVICES <br />r .ENNEURunways /Animal Population No. No. of Confining Cages <br />Sewage Disposal Method <br />Solid Waste Disposal Method <br />Water Supply Source Animal Waste Disposal Method <br />6. CONSULTATION FEE r <br />7. ❑ PLAN CHECKING FEE <br />8. REAL ESTATE <br />REQUEST: Water Well Inspection 13 Sample 13 Title Company <br />Sewage System inspection ❑ Address Tele. No. <br />Escrow No. <br />Seiler Seller Address <br />Telephone No. Seiler 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 regulatio of the San Joaquin Local Health District. <br />APPLICANT'S SIGNATURE Tit l ate <br />FOR DEPARTMENT USE ONLY <br />Fee IS Dale: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & Received By January 31 ❑ July 1 & Received By July 31 <br />REMIT <br />BASE <br />EXPLANATION <br />BILLING <br />B <br />REMITTANCE <br />$ <br />AMOUNT DUE <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEE <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />r <br />P <br />R Iv by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br />•__. ._._._. _�e..�.. �.. ...4....... a.._ ......... i. s.utu��, uceaau nene��r.c.�®varr¢ 9¢na C -.1 l'nu wUW on an. • m avnf ltlrnu r`® a49M <br />