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Applications Will Be PiM-c'11bed When Submitted Properly Completed, Be Sure Vvltign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEERS AND/OR <br /> APPLICANT'S AND/OR APPLICATION IF VEHICLE INVOLVED, GIVE <br /> CTORA ENVIRONMENTAL HEALTH PERMIT/SERVICES Make_ <br /> BROKER AND70R'—`-- Lic. No. <br /> LtC€NSE AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> REGISTRATION Regist. No. <br /> L.`/ 7,Q 9-3 REAL ESTATE INSPECTIONS PLING Color i <br /> NUMBER /G <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> FApplication Date �`g� �Ci� Business/Name To gppear On Permit <br /> .*Type Permit/ServyjeRequested: _ <br /> iAPPlicantName 1'� r` •�NTR1 -+•�S li w Gatti_ Address "IL tQraw <br /> c /5 <br /> Business Telephone No. 0797 !iN4j <br /> ��� Emergency Telephone No. <br /> Property Location/Addressag,�T <br /> dProperty Owner Ok--L bJ )Ql _T Address + W'o'o-C <br /> Operator's Name it ` °` Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> d RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND C❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/No. of Cl 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 _ __ _ Animal Waste Disposal Method <br /> B. CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. PLAN CHECKING FEE71�.%/l ' / 'l rf`/.'1'�' s`� 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 /> SellerSeller 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 law/s/,aryQ rules and egulations of th 6 Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X/! t/�� _.. Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 6 Received By July 37 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE '-- <br /> LESS - - - <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> n <br /> Received by ©ate Receipt No Permit No. Issuance Date Mailed Delivered <br /> I <br /> - APPLICANT—RETLIRNALL COPIES.TO: ENV"INMENTAL HEALTH PERMIT/SERVICES 1601 IF HAZE' 4 AVE.,P.O.Box 2008 STOCKTON.CA 86201 W <br /> '"Elp- "..W <br />