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Applications Will Be Pr�iesed When Submitted Properly Completed.Be Sure-7o 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 <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br /> BROKER AND/OR Lic. No. _ <br /> LICENSE AND/OR EARN ESTABLISHMENTS,HOUSINS Re Is[. No. <br /> REGISTRATION PUBLIC POOL&NATER SAMPUR g <br /> NUMBER REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES ANO KENNELS <br /> /-� ��� <br /> MISCELLANEOUS OEEERMCES /J®�/'- /vyZ(//�L/y � �� <br /> rADDlication Date J 'sl /Nam`e T-opear O eur�'t �/'( <br /> *Type Permit/Service,Reegaueested: <br /> APPlicant Neme Ann / <br /> �SZ�fl1 Business elephone No. Z Emergency Telephone No.I�J <br /> Property Location/Address <br /> i Property Owner Address y5/7 Ai�lo <br /> L Operator's Name !/ Al Address <br /> /r re !r <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 /> ❑ 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 /> 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 4, ge Animal Waste Disposal Method <br /> E. ,IIsi CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> R. 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 of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 6 Receives By January 31 ❑ July 1 S Receives By July 31 <br /> REMIT <br /> S <br /> E EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE ` BILLING REMITTANCE 19' 1 s] <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER 0 <br /> OTHER <br /> 3flp7�1 3 0 <br /> RecelVee by Date Receipt No, Permit No. Issuance Date Mailer Delmeres i <br /> APPLICANT—RETOBNILLd OMATO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1001 E.HAZELTON AVE.,P.O.ba as00 STOCKTON,CA Wel N <br /> I <br />