Laserfiche WebLink
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 <br /> APPLICANT'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make —_ <br /> BROKER AND/OR L'IC. NO. <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> REGISTRATION PWLIC POOLS,WATER SAMPLING Regist. No. <br /> NUMBER REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> FApplication Date 07-08 Business/Name To Appear On Permit _ <br /> troperty <br /> ype Permit/Service Requested:�i(L� A MieUA7 j� '� _< _2f MO U1/}LpplicantName Cfl'e of . n Address 2-21 � �/AAE 5 r,Business Telephone No. Emergency Telephone No.Location/Address EL <br /> i Property Owner -C, <br /> !I Ine 49 r) / Address <br /> L Operator's Name 7F/ Te 7> ` Z fA 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 J <br /> ALL APPLICANTS: Total Employees Including Operators <br /> Z. HOUSING / <br /> ❑ HOTEVMOTEL/No.of Units ❑ CERTIFICATE OF OCCUPANCY Q !65 <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 LM] <br /> 13 KENNEL/Runways /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> W ter.,Supply Source Animal Waste Disposal Method <br /> 6. 129,CONSULTATION FEE UU DE2'C.Me OAP)_'t n9ldeA ❑ BUSINESS LICENSE <br /> T. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> e. 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. Seiler Agent Name <br /> Service Request For Date <br /> I hereby certify that I have prepared this application and that the work will be dorm in accordance with San Joaquin County <br /> ordinances, state laws d rules and regul ie s o San Joaquin Local Health District. i lam` fIt ca� <br /> APPLICANT'S SIGNATURE _ Title �19 <br /> P�1w <br /> �ECEA//F^r' bate 0 1—Q 00— i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 a Received By July 31 <br /> BE S TED REMIT <br /> BILLING REMITTANCE'BASE EXPLANATION DATE DATE REMITAMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt NO. Permit No. Issuance Data Mailed Cal."red i <br /> AMN.ICANT—RETMaN C40FAMTO- ENVIRONMENTAL HEALTH PERMIT/SERVICES 1001 E.HA=ELTON AVE.,P.O.Sea met STo itTON,CA Man W <br />