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Applications WIII B sed When Submitted Property Completed. BTo Sign The Application. <br /> • AL'PU 'ATIS1lu <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S ANO/OR FOOD ESTABLISHMENTS.HOUSING M P <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLI4 -- <br /> BROKER AND/OR M-AL ESTATE INSPECTIONS � Q NO. <br /> .IrENSE ANO/OR ?1E "RY HAVCHES AND PFNNF ist. No. <br /> 3TRATION Ik? iALLA?1. .2'A SERVI(A i a g <br /> I. .8ER — Olor <br /> ('Application Date Business/Name To Appear On Permit <br /> Type Permit/Service Requested: <br /> 'Applicant Name F?S $tOCl ransfe.rj-ReCJ/.C� Address zWeber—SVP--,—$�kt01Lg5j205 <br /> 2, Business Telephone No. Emergency Telephone No. <br /> Property Location/Address—2 _ 4Jeb",—S-tr}ck _ <br /> Property Owner Address <br /> Operator's Name Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum S^Ating Cacp.city <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> 7 FOOD PROCESSING PLANT C COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ RAR ❑ ITINL'?ANT RESTAURANT <br /> ❑ CONFECTIONARY STORE C 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 ❑ CERTIFICATFE 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 /> "O. OF PUBLIC SERVED (Connections) <br /> ^. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL n NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> .EI`INEL/Runways /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Clupply Source Animal Waste Disposal Method <br /> S. 0 CONSVI_TATION FEE —Sol i rdl t?PE1"Cfl'I t _. <br /> 7. 4D .PLA'I CHECKING -F-E <br /> 8. REAL Ecr`.TE <br /> REQUEST: Water Well Inspection Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <br /> Escrow No. <br /> Seller Seller Address _ <br /> Telephone No. Seller Aoent 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 S..,1n Joaquin Local Health D'::trict. <br /> APPLICANT'S SIGNATURE X Title 171:4.te <br /> FOR DEPARTMENT USE ONLY <br /> i Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑_EACH_ 13 January 1 6 Received By January?t ❑ July 1 d Received By July 31 <br /> I BILLING REMITTANCE 3 REMIT <br /> f BASE EXPLANATION DATE GATE REMITTED AMOUNT DUE CHECKED <br /> _ AMOUNT_ <br /> FEE _0� See <br /> '3/4./89 -,W-7—q <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER DAYS FR Mv�1BILLLLINttG'TD TE, UE:ACCO TS 3C <br /> OTHER <br /> i <br /> l <br /> Received by Date ReceI�'?to. Permit No. Issuance Da`o Mailed D9'�ve-e <br />