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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR <br /> APPLICANT'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> l CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make----- <br /> BROKER AND/OR <br /> LICENSE AND/OR <br /> FOOD LS,HOUSING <br /> LicNo.... <br /> REGISTRATION —PUBLIC POOLS,WATENSAMPLNG Regist.NUMBER <br /> REAL ESTATE INSPECTIONS Color__,_ ____ _. <br /> POULTRT RANCHES AND KENtf{Lg <br /> Mlo SERVICES <br /> Appear <br /> ! /t yO� <br /> [-Application Date __ Business/Name To Appearr O On Permit ( `-'t ­0 <br /> { <br /> *Type Permit/Service Requested: _ ~--� ---- �- — - ---- <br /> u Applicant Name Envi ronmenta _ Science_&_E_ng neeri%dfess���—�pX�$E;�d�n@v_i 17 e, FT Ori da —3-MO-2 <br /> Business Telephone No - Emergency Telephone No. <br /> Property Location/Address-RE.---� p-�)a Army Oen-Dt--_Roth_Rd___P-errrLi-t <br /> J Property Owner _. Address W_ <br /> L 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 /> 13 ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> F ❑ 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 /> ❑ HOTEUMOTEUNo. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> I ❑ MOBILE HOME PARK/No.of Spaces r^ <br /> f 3. WATER QUALITY ❑ WATER SAMPLE(Bacterial)' ❑ CHEMICAL p)• <br /> !f ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> N0, OF PUBLIC SERVED (Connections) <br /> fA. RECREATIONAL HEALTH 13 SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> p S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> ❑ KENNEL/Runways /Animal Population No. N <br /> Sewage Disposal Method o.of Confining Cages <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> B. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> h T. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> r S. REAL ESTATE <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 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 regulations of the San Joaquin Local Health District. <br /> APPLICANTS SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 7 A Received By January 31 ❑ July t d Received By July 31 <br /> TBILLING REMITTANCE" j REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE $143.50 1. 1 Additional 8/11/d16 Rue Immediately $143.50 X <br /> LESS rS. <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I OTHER <br /> OTHER <br /> e <br /> n <br /> Received by Dale Receipt No. Permit No, Iaawrlee Day Mailed peli,m,� e I <br /> A►rLICANT—RETURMALL`LCCOIRMTO: ENVULONNEWAL NEALTN'ERMfT/SERvtcES1501 E.MAZFL70M AVE..P.O.soa 1005 STQCIITON,G 116107 W E <br />