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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 Make ---- <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> BROKER AND/OR Lid. No. -- <br /> LICENSE AND/OR FOOD ESTAGUSHMENTE,HOUSING RegistNo <br /> REGISTRATION PUNLIC POOL . .E,WATER SAMPLING --- <br /> NUMBER REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> rAppHcation Date �` �—._ u�W` ss/Nam To Appear On Permit <br /> aType Permit/Service Requested: /4j�;, ;ZC .j UST <br /> Applicant Name Tus -- Address ` jam ' �� � � <br /> u _ Business Tele Prone No. __ Emergency Telephone No. <br /> 157, <br /> Property Location/Addressa"�j'�'� <br /> iProperty Owner r? -S -T� Address <br /> L Operator's Name AddressZZ Z7 <br /> ' ` <br /> 1. FOOD ESTABLISHMENTS Total Building Sq, Footage Restaurant,Maximum Seating Capacity <br /> 13 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 /> 3. 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 /> 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 0 Animal Waste Disposal Method <br /> 5.,tTCONSULTATION FEE ❑ 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. 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 /> APPLICANT'S SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 6 Received By January 31 ❑ July 1 6 Received By July 31 <br /> BE S REMIT <br /> BILLING REMITTANCE'BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE G� '�_ /� ,'`.. afl -(1() <br /> LESS y� '� CJ <br /> PRORATION r rT"� <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> h <br /> 1/2 Af <br /> i <br /> 0 <br /> Received by Date —^ Receipt No. Permit No. Issuance Date Mailed Delivered = <br /> APPLICANT—RETL RUALL.CCaLES.TO: ENV-- 'VMENTAL HEALTH PERMIT/SERVICES 16011 E.HAZE?" AVE.,P.O.Bo=2000 STOCKTON,CA 96401 W <br />