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Applications Will 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 <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make -- <br /> BROKER AND/OR Lic. NO. — <br /> LICENSE AND/OR F000 ESTABLISHMENTS,HOUSING <br /> REGISTRATION PUBLIC POOLS WATER SAMPLING Regisl. NO. <br /> NUMBER REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> O MISCELLANEOUS SERVICES <br /> FApplication Date _7—.2%51— gS _ Business/Name To A ear On Permit _ _ <br /> Type Permit/Service R ested: <br /> A Iicant eme Address���7 GJ i[�ai J <br /> Z Business Telephone No. Emergency Telephone No.I P-4 C25 <br /> Property Location/Address <br /> jProperty Owner `� d S_ d e <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 ❑ 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 /> A. 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 /> B. ® CONSULTATION FEE Z5 ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 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 regulations of the San Joaquin Local Health District. <br /> /G� y ry _ <br /> APPLICANT'S SIGNATURE X-- '"✓�' �� _ Title C�li— Lt,-L',`tZ- — Date✓ —�0'6 <br /> R DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 S Received By July 31 <br /> BILLING REMITTANCE STED REMIT <br /> BASE EXPLANATION DATE DATE REMITAMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 0(] /7�/ l''�' <br /> LESS <br /> PRORATION /J <br /> PWA - 45 <br /> PENALTY <br /> OTHER <br /> OTHER <br /> RecelVed by Date Receipt No, Permit No. Issuance Date Malled Delivered i <br /> APPLICA —RET3YN CCOMTO: EMOOMMENTAL HEALTH PERMIT/SERVICES 1W1 E.HAEELTON AVE.,P.O.ba EAOa STOCKli CA OMI w <br />