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Appticstlons Will Be Processed When Submitted Properly Completed. Be Sure f—oo Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR Make -� <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> BROKER AND/OR Lia. No. —--- <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,HOUSING Regist. No. <br /> REGISTRATION PUBLIC POOLS,WATER SAMPLING —— <br /> NUMBER _ _ _.-- REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> FApplication Date si ess/Name To Appear On Permit e_ -- -- <br /> „Type Permit/Service Requested: 1 0 - <br /> i Applicant Name ---Add Address <br /> U <br /> _ Business Telephone No. . Emergency Telephone No, �--=*<31-30— <br /> ,,Property Location/Address <br /> Property Owner v Address <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 /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/No. of T ❑ 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 /> 5. 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 ��pr�An al Waste Disposal Method <br /> 6. 1p CONSULTATION FEE A LT $tISINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 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 he San Joaquin Local Health District. <br /> 1, �APPLICANT'S SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT W—PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE' S <br /> BASE EXPLANATION DANkO'UNT DUE CHECKED <br /> ATE DATE REMITTED <br /> AMOUNT <br /> FEE E5 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permil No issuance Date Mailed Delivered i <br /> APPLICANT—RETURN JILLC 3R1ES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 F-HAZELTON AVE.,P.O.Bo=2009 STOCKTON,CA 95201 W <br />