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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR <br /> APPLICANT'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br /> BROKER AND/OR <br /> LICENSE AND/OR FOOD ESTASLMNMENTE,MOUSING Lic. No. <br /> REGISTRATION PUBLIC POOLE,WATER SAMPUNG Regist. No. <br /> NUMBER REAL ESTATE INSPECTIONS - Color <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> Application Date Business/Nam To Appear On Per <br /> eType Permit/Service Requested: N41 7�NK ye ,a„_ 1. — <br /> f <br /> Applicant NameML. —Address.p376/ A_ <br /> _Business Telephone No. !2/&9 s2n5' <br /> (z Emergency Telephone No�R��t� <br /> Property Location/Adtlress G, <br /> Property Owner �Da'S <br /> Address 6.� a ,444� L�'S9 x�_,kayyy <br /> L Operator's Name /!Le 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 ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No.of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> Z. 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 /> ❑ KENNEURunwaya /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 /> 6. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> A. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample 13 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 t have repared this application and that the work will be done in accordance with San Joaquin County <br /> s, <br /> ordinancest l�andle"sgul I s ofthe San quin Local Health District. <br /> APPLICANTS SIGNAT RE Z _ Title &�wzitor� Date 53-4�� <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EA CM ❑ January 1 a Receives By January 31 ❑ July 1 It Received By July 31 <br /> BILLING REMITTANCE E REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> EJ AMOUNT <br /> FEE O TO _6-q0 .00 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ov <br /> OTHER rL <br /> OTHER <br /> 11,E 3-7-Ole C lv4 n <br /> Receives DY Dins Receipt No. Permit No. Issuance Date Wiled DNivens o <br /> AMLICANT—RETION roam TO: MONMENTAL HEALTH PEARNT/UmVICEaY <br /> 1E01 E.K TON AVE,P.O.Ma 1bM BTOCRTON,CA ellmr <br />