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Applications Will Be Prlx:neetl When Submitted Property 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 Lic.No. <br /> LICENSE AND/OR FOOD ESTABLISHMENTS.HOUSING R ISt. NO. <br /> REGISTRATION PUBLIC POOLS,WATER SAMPLING eg -- <br /> NUMBER REAL ESTATE INSPECTIONS - Color <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES c I <br /> ,[Application Date Business/Na e T Appear On Permit Ed cA 16.0 L tr Y A461 ,fAfC. <br /> Type Permit/Service Requested: 6 <br /> Applicant Name E 5 CA&AP I it IF dpl 1j,C /A.Eddress /l}f LA EscN/��i CA 9S2 20 <br /> _ Business Telephone No. 09 S'7 �2 Emergency Telephone No. d!j <br /> ff 7?071 <br /> Property Location/Address MS CA/GAJ CA 9S-A <br /> /I/ <br /> Property Owner JOr12Y/Ar ` 544Aee i d t Address 2 &I Ate ex 9SILZO <br /> Operator's Name__ %'x 47yE P 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 /> Z. HOUSING <br /> ❑ HOTEVMOTEL/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 /> A. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. 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 ❑ BUSINESS LICENSE <br /> T. ❑ 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 /> APPLICANTS SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE f <br /> BABE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> Y <br /> OTHER <br /> Received by Dale Receipt No. Permil No. Issuance Date Mailed Delivered <br /> I <br /> APPLICANT—RETMWJNA.CAaraTO: ENYIaOM1ENTAL HEALTH PERMIT/SERVICES 1e01 E.NAIELTON AVE.,P.O.Baa 31101 iIOCIRON,C/1 aSSM1 M <br />