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Applications Will Be ProTessedWrien Submitted Properly Completed. Be Sure 7W Sign-Ae 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 Llc. No. <br /> LICENSE AND/OR FOOD ESTABLISHMENTS.HOUSING Regisl. No.---- <br /> REGISTRATION <br /> o. __REGISTRATION PUBLIC POOLS,WATER SAMPLING <br /> NUMBER REAL ESTATE INSPECTIONS Color — <br /> POULTRT RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES '/ <br /> rApplication Date S/8/� S _ Business/Name To Appear On Permit VU LEFU. <br /> aType Permit/Service Requests .�7nJ✓9.�-0� un' <gAaUN� <br /> 37 <br /> APPlicant Name I�AAJ�E 2.. �LTERP/G�S K• Address 27ao J CJAS'iFrn tG'ro.J,, ciC.CTa 9S t3 <br /> o _—Business Telephone No. A4 S--35/.x/ Emergency Telephone No. <br /> Property Location/Address h/0.2 E CF1/fJ.P. ZJA!l_ <br /> dProperty Owner 42bezrA 6/ONAAWO'Lp _ Address �A) <br /> yOperator's Name �' T»El1 TON Address 1�� F e/6Q.1r0?_ 4/AN jMCKTDA) <br /> 1. FOOD ESTABLISHMENTS r 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 <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 /> A. 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 —Dnp'" BUSINESS LICENSE <br /> 7. PLAN CHECKING FEE Albs ��•"� � DANCE PERMIT <br /> B. 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 /> APPLICANT'S SIGNATU X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 S Received By July Jt <br /> REMIT <br /> BILLING REMITTANCE <br /> BS <br /> BABE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER S <br /> —e <br /> OTHER <br /> � �fr-frS <br /> RacenM aY Date Receipt No. Permit No. Issuance Data Moiled Delivered i <br /> APPLICANT—RETIIM/ CWIESTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTOM AVE.,P.O.Alex R STOCKTON,CA Nunn W <br />