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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To 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 Make -- <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> BROKER AND/OR LIC. NO. -- <br /> LICENSE AND/OR F000 ESTABLISHMENTS,HOUSING Regist. No. <br /> REGISTRATION PUaLIC POOLS,WATER SAMPLING <br /> NUMBER _ REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> �^ MISCELLANEOUS SERVICES - y� P <br /> rApplication Date (l �p Business/Name To Appear n �rmi�lC �J <br /> a Type Permit/Service uested:�E�ri0 W6 i—� ; mei <br /> Applicant Name �� Ld - L -- Addressy Ji✓�tTIIT 6 r -�� ��'—fin '?` <br /> O Rusin ss Telephone No. d�2/�2 Emergency Telephone No. �s <br /> Property Location/Addressyy�� ��Q.d��s' ,P7 a� 7 <br /> Property Owner =stc _ _l,I bs�L.d All Address a <br /> L Operator's Name S7L= Address k <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 /> O HOTEVMOTEL/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 /> 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 DISDOSal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> 6. Id CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> S. REAL ESTATE <br /> REQUEST. Water Well Inspection❑ Semple❑ 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 reg It of t In Joaquin Local Health 1Diistrict. <br /> APPLICANTS SIGNATURE X— _ Title • r e Date 4 — 1['—CC c 4 <br /> FOR DEPARTMENT USE ONLY <br /> Foe Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 S Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS BO <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER - <br /> OTHER ^_ <br /> s <br /> Received by Date Receipt No. Permd Na Issuance Dete Mailed Delivered <br /> ��IIAPPLICANT-RETIlYlJ COR TO: E MOMMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.see SIGN STOCKTON.CA 96201 J I <br />