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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S Al APPLICATION IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR Make - <br /> CONTRACTORAND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> BROKER AND/OR LIC. No. - --- <br /> LICENSE Al FOOD ESTABLISHMENTS,HOUSING RBgist. NO. <br /> REGISTRATION PUBLIC POOLS,WATER SAMPLING <br /> NUMBER REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> �\ MISCELLANEOUS SERVICES <br /> [Application Date o "aa 'r usin ss/Na o App r On Permit ` /' - <br /> Type Permit/Service Requested: I <br /> Applicant Name Address G r <br /> p _._ Business T ephone No. yQ �/ 91Fl� Emergency Tel hone No. X7 Cf r 9 <br /> Property Location/Address Q`O r '� A060 A-? _ <br /> Property Owner S Jl/ts' `v Address <br /> L Operator's Name O�t/ /� Le f S 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 I] 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 Z^ <br /> 2. HOUSING <br /> ❑ HOTEUMOTEVNo.of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces iilE <br /> 2. WATER QUALITY ll WATER SAMPLE(Bacterial) 13 CHEMICAL <br /> 0 PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO.OF PUBLIC SERVED (Connections) <br /> e. 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. CONSULTATION FEE a5 ❑ 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 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and ru nd regulations of the San Joaquin Local Health District. <br /> APPLICANTS SIGNATURE Title dk4 t . Date�✓ p er{ J <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE [3 EACH ❑ January 1 a Received By January 31 ❑ July 1 A Received By July 31 <br /> BILLING REMITTANCE S REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE rQY 0Is;LESS � <br /> PRORATION <br /> PLUS <br /> PENALTY QiG <br /> OTHER <br /> OTHER <br /> ,01 /o as �,- <br /> Receive0 W Date Receipt No. PormH No, Issuance Oale Mailed Delivered = <br /> APPLICANT—RETWMJLL.00jAU O: ENVMMMENTAL HEALTN PERMITAERVICES 1101 E.HAZELTON AVE..P.O.ba]ROB STOCKTON,CA 85201 N <br />