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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ENGINEER'S AND/OR GENERAL <br /> APPLICANT'S ANO/OR APPLICATION IF VEHICLE INVOLVED, GIVE <br /> CONTBROKEACTOR R AND/OND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br /> COOKER AND/OR <br /> LICENSE AND/OR FOOD ESTABLISHMENTS.HOUSING Lic. No. <br /> REGISTRATION -- <br /> NUMBER 467293 PUNLIC POOLS.WATER SAMPLING Regist. No: _ <br /> REAL ESTATE INSPECTIONS Color <br /> _— <br /> [Application <br /> RANCHES AND KENNELS <br /> /1 2, MISCELLANEOUS SERVICES <br /> rTyplicermi Date O` I D10 Business/Name To Appear Precision Industries, Inc. <br /> !Property <br /> Type PermiVServica R PPear On Permit equested: __ApplicantName Precision Industries, Inc. ddress2191 NaW DriveStockton BusinessTelephoneNo. (209) 462-9911 Location/Address 620 San Juan Stockton Emergency Telephone Nd.�209) 944=9195 <br /> Property Owner Bill COrr1CJOn Address 620 <br /> Operator's Name an Juan Stockton Ryp-o fis} <br /> L <br /> 1. FOOD ESTABLISHMENTS Address <br /> 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 ❑ <br /> 13 ROADSIDE FOOD STAND 13 LIQUOR STORE 11 BAR BAKERY <br /> 13 ITINERANT RES <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER 11FOOD DEMONSTRATION ❑ FOOD VENDOR TAURANT <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 <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 /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> ❑ KENNEL/Runways /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 /> S. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 8 R <br /> . R. PLAN CHECKING FEE 11DANCE PERMIT <br /> BEAL ESTATE <br /> REQUEST: Water Well Inspection❑ Sample❑ Title Company <br /> Sewage System Inspection ❑ Address_ -- <br /> Escrow No. <br /> Tele. 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 /> APPLICANT'S SIGNATURE X <br /> —_ Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: Cl ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t S Racelved By January 31 ❑JuIY 1 8 Received ay July 3t <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNTOUE CHECKED <br /> FEE <br /> 90- AMOUNTLESA' mo <br /> PRORATION 80 W <br /> PRATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> S/23/g-b moo\ -- <br /> R vad by Dar R —� <br /> pt No, P lHAZY a Date MaIIrM <br /> APPLICAMf—RETNaNA GO,,,,TO: Em�VENTAL HEALTH PERMIT/SERVICES Delrvaretl —IJiI <br /> I tpl E.MA2f AYE.,P.O.bz ESOs sTOCKTON,CA s l <br />