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Applications Will Be Prcwssed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/ORMake - - -- <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES 1-C. No. -- - <br /> BROKER AND/OR FOOD ESTABLISHMENTS.HOUSING <br /> LICENSE AND/OR PUBLIC POOLS WATER SAMPLING Regisl. NO. <br /> REGISTRATION REAL ESTATE INSPECTIONS Color <br /> NUMBER POULTRY RANCHES AND KENNELS <br /> L MISCELLANEOUS SERVICESo <br /> 1 jApplicanthleme <br /> Application Date 3�`�(/ B siness/Name TO Appear On Permit — <br /> pePermiVServiCeRequGated: t.�^'� r o!E iC•O•�.s�eA «�✓ ;oee ,y"'A' .e A. AddressBus' ess Telephone No. P6� P! ��f� Emergency Telephone No. <br /> operty Location/Address VaclP t'.✓!1o/y/7A+Ar to �i1'"� S ec os- <br /> operty Owner Address <br /> perator's Name �i'-t'o✓ Address ,!74119 FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Seating CePBCHy <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 <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING <br /> ❑ HOTEUMOTEL/No.of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces <br /> S. 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 /> 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 <br /> rules and regulations off the San Joaquin Local Health District, <br /> APPLICANTS SIGNATURE X Title .c.nGN 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 6 Received By July 31 <br /> BILLING REMITTANCE R REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE ryy <br /> LESS - <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER / <br /> OTHER _ <br /> Received by Date Receipt No, Permit No. Issuance Date Mailed bell i <br /> APPLICANT—RETL� CCMMaTO: ENYIaOHMENTAL HEALTH PERMIT/SERVICES lea/E.HAZELTON AVE.,P.O.Sea 200 STOCKTBM,nJ1SM01 w <br />