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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 />FApplication Date / <br />a Type Permit/Semice <br />Applicant Name I <br />d Property Owner <br />L Operator's Nam <br />2023 t1 _"_ <br />Applications Will Be Processed When Submitted Properly Completed. Be Sure %Slpn The Application. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />// <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />Business <br />F000 ESTABLISHMENTS, HOUSING <br />PUBLIC POOLS WATER SAMPLING <br />REAL ESTATE INSPECTIONS <br />POULTRY RANCHES AND KENNELS <br />MISCELLANEOUS SERVICES <br />To AoDearAn Permil G <br />Address <br />Address <br />GENERAL <br />IF VEHICLE INVOLVED, GIVE <br />Make <br />Lic. No. <br />Regist. No <br />Color <br />e Arwr - c <br />s <br />:y Te Pholle No. s'Q <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 />2. 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 />a. RECREATIONAL HEALTH ❑ SWIMMING POOL <br />❑ CERTIFICATE OF OCCUPANCY <br />CHEMICAL <br />❑ WATER HAULER <br />❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br />5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br />❑ KENNEURunways /Animal Population No. <br />Sewage Disposal Method <br />Solid Waste Disposal Method <br />No. of Confining Cages <br />Water Supply Source Animal Waste Disposal Method <br />S. 12 CONSULTATION FEE BUSINESS LICENSE <br />T. ❑ PLAN CHECKING FEE jW ❑ DANCE PERMIT <br />S. REAL ESTATE <br />REQUEST: Water Well Inspection 13 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 the San Joaquin Local Health �District. <br />APPLICANTS SIGNATURE X7L� .r7�iL%J _Title �G*�� Date -6/ZS/pj— <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNITr ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ J.IY 1 S Recened By July 31 <br />BASE <br />EXPLANATION BILLING <br />REMITTANCE <br />5 <br />AMOUNT DUE <br />REMIT <br />CHECKED <br />DATE <br />OAT <br />REMITTED <br />AMOUNT <br />FEE <br /><- - <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />by <br />R�eo�iram_acn,eu .,, Datet No <br />teme m. cuvmnuocuNueceu,.P...pt o I..... ^•cleamcce Date„c ^^Mailed_ Dalfwre0-._-__v- <br />