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metled R9cetet No Pa/mit No. Deeivere0 <br />Recewe0 Uy Date <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH pERmIT4ERVICEE <br />!swam, Dale <br />1601 E. HAZELTON AVE.. P.O. Cox 200, RTOCRTON. CA *Mt <br />FOR DEPARTMENT USE ONLY <br />in PER SITE 0 EACH 0 January 1 & Rece.yett By January 3 t <br />REMITTANCE <br />DATE <br />$ <br />REMITTED <br />1 BILLING <br />DATE <br />REMIT <br />CHECKED <br />AMOUNT <br />AMOUNT DUE <br />Fee Is Due: Z ANNUALLY 0 PCP UNIT <br />BASE <br />FEE <br />LESS <br />PPORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />EXPLANATION <br />July 1 t!. ReedtP4t0 By July 31 <br />-4 .7.1 r . <br /> . ... Se Sure To Sign The Application <br />ENGINEERS AND OP <br />APPLICANT'S AND, OP <br />CONTRACTOR AND/OP <br />BROKER AND/OR <br />rENSE ANO.OR <br />3TRATION <br />I. aER <br />APPLICATION <br />4VIRONMENTAL HEALTH PERMIT/SU% <br />FOOD ESTABLISHMENTS, HOUSING <br />PUBLIC POOLS. WATER SAMPUNG <br />REAL ESTATE INSPECTIONS <br />POULTRY RANCHES AND KENNELS <br />MISCELLANEOUS SERVICES <br />IF VEHICLE INVOLVED, GIVE <br />Make <br />Lic. No. <br />Regist. No <br />Color <br />'Application Date././...FA-.$ Business/Name To Appear On Permit ,4'5'/r r ceeizt yeStle.P:._:-._5:0' -e /i"P/A,15 1,4lrexAVA,•-/. e.,,,,e.4. ) Type Permit/Sigrvi <br />-- • - • <br />.1 Applicant Name •'-'1'-5 •Av6"":40A-e.w.,...-/s1 ef..4,s,,G4.,...,4 ....-- — Address dtc'/ *-155/7c7444-' 3.e,7- 7 .90.*‘‘.A64 - e'49 gra-78 <br />... Emergency Telephone No. <br />FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br />0 RESTAURANT 0 FOOD MARKET RETAIL 0 FOOD MARKET WHOLESALE 0 MEAT MARKET <br />0 FOOD PROCESSING PLANT 0 COMMISSARY 0 ICE PLANT 0 BAKERY <br />0 ROADSIDE FOOD STAND 0 LIQUOR STORE 0 BAR 0 ITINERANT RESTAURANT <br />0 CONFECTIONARY STORE 0 FOOD SALVAGER 0 FOOD DEMONSTRATION 0 FOOD VENDOR <br />0 VENDING MACHINES/No. of _ 0 MOBILE FOOD PREP. UNIT 0 VENDING VEHICLE <br />0 FOOD CROP HARVESTING/No. of Field Employees <br />ALL APPLICANTS: Total Employees Including Operators <br />HOUSING <br />0 HOTEL/MOTEL/No. of Units ___ 0 CERTIFICATE OF OCCUPANCY <br />0 MOBILE HOME PARK/No. of Spaces <br />WATER DUALITY 0 WATER SAMPLE (Bacterial) 0 CHEMICAL 0 PUBLIC WATER SYSTEM 0 SURFACE WATER SUPPLY 0 WATER HAULER <br />NO. OF PUBLIC SERVED (Connections) <br />RECREATIONAL HEALTH 0 SWIMMING POOL 0 SPA 0 WADING POOL 0 NATURAL BATHING PLACE <br />S. VECTOR CONTROL 0 POULTRY FARM/Maximum No. of Birds <br />r :ENNEL/Runways . /Animal Population No. <br />Sewage Disposal Method <br />Solid Waste Disposal Method <br />Water Supply Source z Anpal Watt. Disposal Method <br />6, 411 CONSULTATION FEE 4"4 "". '" . <br />7. 0 PLAN CHECKING FEE <br />usineas Telephone No. (27a_2 7.5'?: <br />Property -0CatiOn/A0cress 4'44 (cto ,454.1 _5- c.44.1., C4 <br />Property Owner ---5—,1?-‘-4/ dv10744," <br />Operators Name <br />r AA cid dd rreesss A°•5 eUr ?75-2 <br />, • <br />No. of Confining Cages <br />8. REAL ESTATE <br />REQUEST: Water Well Inspection0 Sample 0 Tine Company ._. . <br />Sewage System Inspection 0 Address _. <br />Escrow No. _ <br />Seller _ <br />Seller Address <br />Telephone No _ Seller Agent Name <br />Service Request For Date -- <br />Tele No <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 San Joaquin Local Health District. <br />7c:0,4e/lAre'/) 7 2/to .(‹r,-,7 .-"A-47`r-6" e ate <br />APPLICANT'S SIGNATURE X