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Applications Will Be Processed When Submitted Properly Completed, Be Sure T o Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AN OA <br /> AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S <br /> CONTRACTOR ANO/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make _ <br /> BROKER AND/OR Lic. No. <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> REGISTRATION PUBLIC POOLS.WATER SAMPLING Regist. No. <br /> NUMBER REAL E37►TE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES 65 <br /> rApplication Date � P✓ Business/Na�9e Ty A pear,On Pgrm� /�'/ < // <br /> Type Permit/Service Requested: /.SLG 9lGf / <br /> Applicant Name Sf / ` __ Address_ Cl/// Al- <br /> rl �—Busine Teleph ne No. 9 _33H(J Emerg nc Telephone No. <br /> (Property Location/Address G5� y y��7• <br /> iProperty Owner !(R' ddress <br /> L O /32/ E. <br /> erator's Name / / <br /> Operator's Address ?• eli/— �7/30 T77-11f 2- <br /> 1. <br /> —/ fZ- <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/MOTEVNo.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 /> 0. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> ❑ KENNEVRunways /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 /> S. CONSULTATION FEE 017 0 13 BUSINESS LICENSE <br /> 7. ) PLAN CHECKING FEE 9!5—' ❑ DANCE PERMIT <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample E3 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 certity that I have p pared this app ice and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws d es aan/n reg/u/lI to of he San Joaquin Local Health District.../,L, <br /> APPLICANTS SIGNATURE X ��L-�✓�+-D� "/' /'Ae .(�Z �7 <br /> Titin��-(�� Date <br /> OR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 3 Received By January 31 ❑ July 1 S Received By July 31 <br /> BILLING REMITTANCE' $ REMIT <br /> BADE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 7� — / f <br /> LESS <br /> PRORATION <br /> jz <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -------------------- <br /> Cs - 3 7 <br /> Rac Dy 1e Receipt No. Permit No. IMuanro Dete Ma11M Delivered ° <br /> APPLICANT—RETUANJLLCCAUES,TO: EHYMONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Boa 2M STOCKTON.CA$$M <br /> W <br />