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Applications Will Ba 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 FOOD ESTABLISHMENT&HOUSING Regist. No. - <br /> REGISTRATION ,( cy 0 / PUBLIC MES MATER SAMPUNS <br /> NUMBER / REAL ESTATE INSPECTIONS Color <br /> ' POULTRV RANCHES AND KENNEL{ <br /> MISCELLANEOUS SERVICES <br /> Application Date )/ Business/Name To Appear On Permit �CJ7Ps�✓ /hf 7f9 -��'7 /�G <br /> rType Permit/Service Requested:'t (4 Cw.i — / Grs-f 7A+^'L/ yam•r <br /> Applicant Name,/12 �M �� Address �ff� '07 '4-- gord �d/tea-r/A��fif✓ <br /> _ Business Telephone No. 9 �`f x 2Y Emergency Telephone No. c <br /> (Property Location/Address - C <br /> Property Owner ff le c Address /l �/ �' e*1-1�f <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 /> 2. HOUSING <br /> ❑ HOTEL/MOTELJNo.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 /> B. 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 /> 6. CONSULTATION FEE ❑ BUSINESS LICENSE <br /> T. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> S. REAL ESTATE #a 'sSUD <br /> REQUEST: Water Well Inspection❑ Sample[3 Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <br /> Escrow No. <br /> Setter 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, rules and reguI ti s of the San Joaquin Local Health District. -7 <br /> APPLICANT'S SIGNATURE �� '/� Title �*"N'f Date <br /> FOR DEPARTMENT USE ONLY <br /> FOR Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July t 8 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BABE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> r AMOUNT <br /> FEE Ott f- J OO <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY I4 <br /> OTHER <br /> OTHER <br /> 9W 2-7-9% <br /> Received by Date Receipt No, Permit No. IMuerlce Dab Mailed Delivered I <br /> APPLICANT-RETUaN�C46 T0: ENVIRONMENTAL HEALTH PERMIT/SERVICES 7Ml E.HAULTON AVE.,P.O.ave]see STOC"M.G e l N <br />