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Applications Will Be Pro .aed When Submitted Properly Completed. Be Sure w Sign The Application. <br /> SAN JOAOUIN 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 /> rApplication Date S —8 — 8 S Business/Name To Appear On Permits <br /> Type Permit/Servi�Rtequested: V'-'d -r•- :tc e 1 I..c{ �u o.. <br /> Applicant Name 'F �- s� Address <br /> Y S (o�-kT ,., C4 952117_ Business Telephone No. 9 S I _ 930 Emergency Telephone No. <br /> Property Location/Address 15 S O E ✓J +> �+ M Y--� A v ST I.0 I r <br /> A F- A ,�. 9n�.,— i <br /> Property Owner To .� 0"1✓o j o� ..,/ ,.., i•.. c _ Address I - - - <br /> L Operator's Name 1 11 o�]-.o To w .+ .-� c Address I S S o F' A LwJ <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 /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No.of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces ,/t , <br /> 3. WATER QUALITY ❑ WATER SAMPLE(Bacterial) 13 CHEMICAL <br /> 1 f <br /> ❑ PUBLIC WATER SYSTEM 13 SURFACE WATER SUPPLY 13 WATER HAULER /Zy 1 <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 /> S. sq CONSULTATION FEE U_L+��.^n ar..c� f'r ❑ BUSINESS LICENSE <br /> 7.)f PLAN CHECKING FEE _ ❑ DANCE PERMIT <br /> S. AL 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 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rubs and regulations of the San Joaquin Local Health District. <br /> APPLICANTS SIGNATURE X w � Title Date FA "— r-a- v— Date 5 —g <br /> FOR DEPARTMENT USE ONLY <br /> Fast Is DW:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 S Received By July 31 <br /> BILLING REMITTANCE S REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE 7-0 <br /> dam— �O /II <br /> LESS V <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER �d V Vo D < <br /> OTHER <br /> Recei by Dale �.•ceipt No. Permit No. lssulmv-'te Mailed Delivered i <br /> APP ICYR—RETIJa1,1 L00PIES TO: "eNTAL HEALTH PERMIT/SERVICES 11101 E.HA!EI NE.,P.D.Bea 1009 STOCKTON,CA 95301 N <br />