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law .. <br /> Applications Will Ba Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> k 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 Lic. NO. <br /> LICENSE AND/OR FOOD ESTABUSHMENTS,HOUSING Regist. NO <br /> REGISTRATION �7 p PUBLIC POOLE.NATER SAMPLING <br /> NUMBER a79 l(P4 kD REAL ESTATE INSPECTIONS Color - <br /> POULTRT RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES � � � ��±LL�pQ Z' <br /> rApplication Date /.2-/(o -f3_S Business/Name To Appear On Permit,�,Aj�9 mran7 eXfJ1✓. LNC- <br /> «Type Permit/Service Requested: 7h nk �P.aTrn/n al'n'7 <br /> plicant Name Ir h V''f_Y) F.en?Y S_ l I n,- .Address <br /> C lA g4511 -_ Busina Tele one No (70 �i-7'-f-a8�61 Emergency Telephone No. <br /> Property Location/Address t - t Y"7/5- ` 617 <br /> Property Owner Tony.'CLtrloz t°-t aL.1 �r�( <br /> . Address i�err n t2mdy lxf'tterCA 1,0'1533(0 <br /> LOPerator's Name�y 2I'7 E�Orrb� It bLtL�Q,Tj1G Address �5l AirCYG -} (�CXIr��,'n\�iS�rjC� Q�IS7f <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. F400tage 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/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 /> t. 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 /> S. CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> S. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ 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 miss and regulations of the San Joaquin Local Health District. <br /> X APPLICANTS SIGNATUREX �A /Ctl A it ' +— Title v-.'y U - <br /> '1'r�4-,E3/ Date ,�- <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Receive!By January 31 ❑ July 1 a Receive!By July 31 <br /> REMIT <br /> BILLING REMITTANCE f <br /> *BASEEXPLANATION DATE DATE REMITTED AMOUNTOUE CHECKED <br /> AMOUNT <br /> FEE Se m <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> CS <br /> Receive!by Date Date RecaiPt No. Pormil No. Issuance Date Meile! Delivers! i <br /> APPLICANT-RETpYLJ1Ll.COR1ER TO: ENVMONMENTAL HEALTH PERMIT♦SERVICES 1 W 1 E.HAIELTON AVE.,P.O.Box fen STOCKTOH,CA 6 l W <br />