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Applications WIII Be P"?&eased 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 Lic. No. ---- <br /> BROKER AND/OR <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,HOUSING Reglst. No. <br /> REGISTRATION PUBLIC POOLS.WATER SAMPLING <br /> NUMBER REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> rApplication Date ` Business/N e T Appe r On Permit — --- <br /> 4J 47-1 DOI <br /> .Type Permit/Service Requested - s <br /> ;Applicant Name _ Address I. <br /> u E er enc Telephone No. —. <br /> Busi ass Telephone No. 9 Y P <br /> (Property Location/Address �Q Q J/� <br /> 'Property Owner f f}/Yl _ Addres/ s- <br /> L Operator's Name Addr s R06? AI. f/U 1 n Al Sf S rx�f'2fw./ <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 /> 2. 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 Disposal Method <br /> Water Supply Source nimal Waste Disposal Method <br /> B. CONSULTATION FEE�d�SODoJr ry BUSINESS LICENSE <br /> 7. tyL PLAN CHECKING FEE'7 35. ❑ 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 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 regula ions of the San Joaquin Local Health District. �7 I� <br /> APPLICANT'S SIGNATURE X f" Title 7—wx/? a'e'✓// Date J �6 ,eJ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Out: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 S Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE t <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Q� �-hk— <br /> Received to, Dete Receipt No. Permit No. [nuance Date Mailed Delivered Z <br /> APPLICANT—RETIIaaI CORIESTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1301 E.HAIELTON AVE.,P.O.ba 2009 STOCKTON,CA e3201 W <br />