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Applications Will Be Ptercessed When Submitted Properly Completed.Be Sur aero Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANTS AND/OR Make <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES -- <br /> BROKER AND/OR Lid. NO. <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> REGISTRATION PUBLIC POOL&WATER SAMPLING Regisl. NO. <br /> NUMBER REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> FAppiication Date _ � Business/Name To Appear On Permit <br /> Type PermiVService R,e�uIe,s,�d <br /> can : <br /> AppliName /�-C7I'LLC Address a <br /> _ Bu;e s Telephone No. Emergency Telephone No. <br /> Property Location/A ress <br /> A Property Owner - Address <br /> L Operator's Name J 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 /> ❑ HOTEUMOTEUNo. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 1. 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 Animal Waste Disposal Method <br /> 0. CONSULTATION FEE S — ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> S. 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 t have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state law nd les and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE XTitle e..it.0. Date 7 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY R UNIT ❑ PER SITE ❑ EACH ❑ JalRwry 1 A Received By January 31 ❑ July 1 A Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATION AMOUM DUE CHECII <br /> DATE DATE REMITTED AMOUNT <br /> FEE r a5 lbb _ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Rec - yI Dae, Receipt No Permit No. Issuance Date Mailed DelivBred I <br /> APPLICANT—AETGBNALLCDWEa TO: ENVIPONMENTAL HEALTH PERMIT/SERVICES 11101 E.HAZE1 SON AVE.,P.O.ft.300S STOCKTON,CA 91 w <br />