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I r , A <br />ENGINEER'S AND/OR <br />APPLICANT'S AND/OR <br />CONTRACTOR AND/OR <br />BROKER AND/OR <br />LICENSE AND/OR <br />REGISTRATION <br />NUMBER <br />rApplication Date— <br />r Type Permit/Service <br />i Applicant Name <br />�gProperty Location/A <br />d Property Owner <br />L Operator's Name I <br />4 <br />Applications WIII Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />FOOD ESTABLISHMENTS, HOUSING <br />PUBLIC POOLS WATER SAMPLING <br />REAL ESTATE INSPECTIONS <br />POULTRY RANCHES AND KENNELS <br />MISCELLANEOUS SERVICES Holly <br />To Appear Qtt ermil T <br />GENERAL <br />IF VEHICLE INVOLVED, GIVE <br />Make <br />Lie. No. <br />Regist. No. <br />Color— -- <br />Business Telephone No. kLU7) Emergency Telephone No. <br />Address ""a �"" ••"��� •" <br />Address 20,500 Holly Dr <br />1. FOOD ESTABLISHMENTS 119500 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 285 <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 />0. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br />S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br />❑ KENNEL/Runways — <br />Sewage Disposal Method <br />Solid Waste Disposal Method <br />/Animal Population No. <br />No. of Confining Cages <br />W <br />Supply Source Animal Waste Disposal Method <br />6.8ACONSULTATION FEE ❑ BUSINESS LICENSE <br />7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br />S. REAL ESTATE <br />REQUEST: Water Well Inspection❑ Sample❑ Title Company <br />Sewage System Inspection ❑ Address - <br />Escrow No <br />Seller <br />Telephone No. <br />Service Request For Date <br />Seller Address <br />Seller Agent Name <br />Tele. No. <br />I hereby certify that I have prepared this applicatio that the work will be done in accordance with San Joaquin County <br />ordinances, state laws, and r les nn egulalions of he an Joaquin Local Health District. <br />APPLICANTS SIGNATURE X _ TLeejm/� sem_ Qom,// ae� et z <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: <br />❑ ANNUALLY <br />❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 <br />❑ July 1 & Received By July 31 <br />REMIT <br />BASE <br />EXPLANATION <br />BILLING <br />REMITTANCE' <br />$ <br />AMOUNT DUE <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEE <br />LESS <br />PRORATIONPLUS <br />—If <br />Oco <br />PENALTY <br />C.l <br />(Y�'r j` <br />OTHER <br />OTHER <br />Received by <br />Date Receipt No. Permit No. Issuance Date Mailed Delivered. <br />ern,eu ... rmemn m. armen....r .. rc.. rr scowr ....1ccn 1M1 1 R.sci rnu ac en a.. eller ernnarnr 'Ass., <br />