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Check i.448 Rc;, „,r. ,- <br /> Applieatlons Will Be rac sed When Submitted Properly Completed. Be Sur�ign 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 Lic. No. <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,HOUSING Regist- No. <br /> REGISTRATION PUBLIC POOLS.WATER SAMPLING <br /> NUMBER REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> rApphcation Date Business/Name To Appear On Permit _ <br /> *Type Permit/Service Requested: <br /> z Applicant Name- - - j indiv; ries., Inc---—Address '�`�? Flav nr;v�.- �tnrktnn 952 6 <br /> u — Business Telephone No. Emergency Telephone No. <br /> (Properly Location/Address - 7 -,,ruck i'-i aza) <br /> d Property Owner _ Address <br /> L Operator's Name _- Address - - -- <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 - -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 DISDOSal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> B. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE - <br /> 7. ❑ PLAN CHECKING FEE — ❑ DANCE PERMIT <br /> B. 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 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 S Received By January 31 ❑ July 1 A Received Sy July 31 <br /> BILLING REMITTANCE' $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> rr]] AMOUNT <br /> FEE - '2, 7�,/. f; �. nn r i Rerit. <br /> LESS <br /> PRORATION <br /> PLUS ---- - - <br /> PENALTY <br /> OTHER <br /> v <br /> m <br /> OTHER <br /> \0 <br /> 0 <br /> 0 <br /> Received by Date Receipt No. Per tinPer 1m No Issuance Date Mailed Del,vered i <br /> APPLICANT—RETLIRMAL.L-COPLE&TC- ENV-0NMENTAL HEALTH PERMITISERVICES 1601 E.HAZF'"%N AVE.,P.O.Box 2000 STOCKTON,CA 95201 Y <br />