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ENGINEERS AND/M <br />APPLICANTS AND/OR <br />CONTRACTOR AND/OA <br />BROKER ANC/011 <br />LICENSE AND/OR <br />REGISTRATION <br />NUMBER <br />[Application Data <br />*Type Permit/Sen <br />S Applicant Name. <br />Appllcatlone WIII Be Proud When Submitted Property Completed. Be Sure T <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />FOOD UTABUSHMEUTS. MOUSING <br />PUBLIC POOU L WATER SAMPLING <br />But ESTATE INSPECTIONS <br />POULTAT RANCHER AND KENNELS <br />MISCELLANEOUS SERVICES <br />Business/Name To ADpear On Permit <br />Address <br />In The Application_ <br />GENERAL <br />IF VEHICLE INVOLVED. GIVE <br />Make <br />Lid. No. <br />Regist. No. <br />Color <br />Emergency Telephone No. <br />A Property Owner A10e81L Loi— Address <br />I Operator's Name —gF12A In Address �,,,, �Wc M H A� - / <br />1. FOOD ESTABLISHMENTS Total Building Sq. Footage RestauranL Maximum Seating Capacity <br />❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br />❑ FOOD PROCESSING PLANT ❑ COMMISSARY <br />❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE <br />❑ CONFECTIONARY STORE ❑ FOOD SALVAGER <br />❑ VENDING MACHINES/No. of <br />❑ FOOD CROP HARVESTING/No. of Field Employees <br />ALL APPLICANTS: Total Employees Including Operators <br />❑ ICE PLANT ❑ BAKERY <br />❑ BAR ❑ ITINERANT RESTAURANT <br />❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br />❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br />2 HOUSING <br />❑ HOTEUMOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br />❑ MOBILE HOME PARK/No. of Spaces <br />1 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 ❑ WAGING POOL ❑ NATURAL BATHING PLACE <br />S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br />❑ KENNEL /Runways /Animal Population No. No. of Confining Gag" <br />Sewage Disposal Method <br />Solid Waste Disposal Method <br />Water Supply Source <br />0. ❑ CONSULTATION FEE 0 <br />T. q PLAN CHECKING FEE66!677%- <br />IL REAL ESTATE <br />REQUEST: <br />Water Well inspection E3 Sample❑ <br />Sewage System Inspection ❑ <br />Escrow No. <br />Seller <br />Telephone No. <br />Animal Waste Disposal Method <br />BUSINESS LICENSE <br />DANCE PERMIT <br />Title Company <br />Address _ <br />_ Seller Address <br />Seller Agent Name _ <br />Tele. No. <br />Service Request For Date <br />I hereby cartify that I have prepared this Application and that the work will be done in accordance with San Joaquin County <br />ordinances. state Is". and rules andel /regulations of the San Joaquin Local Health District .. �.O <br />111� <br />APPLICANT'S SIGNATU4 A �" Title-L'r4 Ir>'- Date �_ ' <br />- ❑ LY [I MR UNIT <br />FOR DEPARTMENT USE ONLY <br />❑ PER SITE ❑ EACH ❑ J*nu*ry 1 A RecerveE BY Jenuery Jt ❑ Juh l a Rece:VeE By A Iy m <br />ref a DW. <br />ANNUAL <br />REMIT <br />REMITTANCE <br />f <br />AMOUNT DUE <br />CHECKED <br />BASE <br />EXPLANATION DATE <br />ATTE <br />DAT/E <br />REMITTED <br />AMOUNT <br />//P'' <br />FEE <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />— <br />OTHER <br />Nle b—b-3Yo jd13gz <br />Rwet NY WN Rece.pl NO. PwmE HO IawarNe Deb WINE DNirMW <br />AIPLICAM-RETMRNALLCOPJES�TO. EAry1,oNMENTAL HEALTH PEAMITMERVICES Leel E N ELTOH AVL VO. ael AM STOCKTON. CA Wel <br />