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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <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 />,Type Permit/Service Reqs <br />Applicant Name, <br />Property Location'/Addret <br />iProperty Owner <br />L Operator's Name <br />SAN JOAOUIN 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 <br />Business/Name To Appear On Permit <br />Telephone <br />Address <br />Address <br />GENERAL <br />IF VEHICLE INVOLVED, GIVE <br />Make <br />Lic. No. <br />Regist. No. _ <br />Color <br />Emergency Telephone No. <br />OOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br />❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br />❑ FOOD PROCESSING PLANT <br />❑ COMMISSARY <br />❑ ICE PLANT <br />❑ BAKERY <br />❑ ROADSIDE FOOD STAND <br />❑ LIQUOR STORE <br />❑ BAR <br />❑ ITINERANT RESTAURANT <br />❑ CONFECTIONARY STORE <br />❑ FOOD SALVAGER <br />❑ FOOD DEMONSTRATION <br />❑ FOOD VENDOR <br />❑ VENDING MACHINES/No. of <br />❑ MOBILE FOOD PREP. UNIT <br />❑ VENDING VEHICLE <br />FOOD CROP HARVESTING/No. of Field Employees <br />ALL APPLICANTS: Total Employees Including Operators <br />Z. HOUSING <br />❑ HOTEUMOTEL/No. of Units <br />❑ MOBILE HOME PARK/No. of Spaces <br />3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ <br />❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY <br />NO. OF PUBLIC SERVED (Connections) <br />e. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br />S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br />❑ KENNEURunways _ <br />Sewage Disposal Method <br />❑ -CERTIFICATE OF OCCUPANCY <br />CHEMICAL <br />❑ WATER HAULER <br />Solid Waste Disposal Method <br />Water Supply Source <br />B. ❑ CONSULTATION FEE <br />T. ❑ PLAN CHECKING FEE <br />/Animal Population No. <br />No. of Confining Cages <br />Animal Waste Disposal Method <br />❑ BUSINESS LICENSE <br />❑ DANCEPERMIT_ <br />B. 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 application and that the work will be done in accordance with San Joaquin County <br />ordinances, state laws, and rules and regulations of)he San Joaquin Local Health District. <br />APPLICANT'S SIGNATURE <br />Title <br />FOR DEPARTMENT USE ONLY <br />Fee Is DW: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Januar, 1 a Received Rv Jan,wry 31 <br />W p-11- A ' Z3b <br />Received by Dow Receipt No Permit No issuance Date Moiled Dsliwrad <br />— APPLICANT—a rrIMM A.COFM&TL: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1N1 E. HAZELTON AVE., P.O. fox 200 STOCKTON, CA Nadi — <br />- V r <br />BABE <br />(PLANATION <br />BILLING <br />REMITTANCE <br />S <br />REMIT <br />DATE <br />DATE <br />REMITTED <br />AMOUNT DUE <br />CHECKED <br />AMOUNT <br />FEE <br />Q. O <br />OL) <br />LESSLESS <br />PRORATION <br />T <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />W p-11- A ' Z3b <br />Received by Dow Receipt No Permit No issuance Date Moiled Dsliwrad <br />— APPLICANT—a rrIMM A.COFM&TL: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1N1 E. HAZELTON AVE., P.O. fox 200 STOCKTON, CA Nadi — <br />