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Applications Will Be Processed When Submitted Property 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 <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make - <br /> BROKER AND/OR Lid.No. <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,HOUSING R8 1St. NO. <br /> REGISTRATION PUBLIC POOLS.WATER SAMPLING 9 <br /> NUMBER _ REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> rApplication Date Business/Name To Appear On Permit A. Teichert & Son , Inc. <br /> e Type Permit/Service Requested: <br /> Applicant Name Mr. Fred Smith Address 1175 Grand River Dr, SayrnmPntn _ <br /> _Business Telephone No. Emergency Telephone No. j <br /> (Property Location/Address 103 S. "E1l St. , Stonkfon <br /> I Property Owner A_ Teich Prt And Snn Address <br /> L Operator's Name 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 ❑ LIOUOR 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.o1 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 /> E. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds <br /> ❑ KENNEVRunwaya /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 /> B. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE _ ❑ DANCE PERMIT <br /> B. 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 I have prepared this application and that the work will be done in accordance with San Joaquin County i <br /> ordinances,state laws,and rules and reg ulatio s Of the San Joaquin Local Health District. <br /> APPLICANTS SIGNATURE X Title President Date Sept. 2. 1986 <br /> FOR DEPARTMENT USE ONLY <br /> Fes Is DUN: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 s Received By January 31 ❑ July 1 S Received By July 31 <br /> BILLING REMITTANCE S REMIT <br /> BASE EXPLANATION DATE GATEREMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 1 <br /> LESS — <br /> PRORATION <br /> PEENA <br /> PENALTY I0•o U <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No, Permd No. IMuance Data Malled Delivered i <br /> APPLICANT—RETURNJIM.CONUTV- EKVMONMENTAL HEALTH MRMIT/SERwCES 1e01 f HA TON AVE.,P.O.Baa a00/ "OCKTON,CA MM N <br /> R/ �1 <br />