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Applications Will Be Processed When Submitted Properly Completed. Be Sure fo Sign 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 F000 ESTABLISHMENTS.HOUSING Regist. NO <br /> REGISTRATION PUBLIC POOL&WATER SAMPLING 8 <br /> NUMBER _ REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> O d� MISCELLANEOUS SERVICES <br /> [Application Date j `I` I1 iness/Na a To A pear On Permit — <br /> eType Permit/Service Requested: - <br /> Applicant Name _ Address <br /> i _ - <br /> _Busi ss Telephong No. Emerge cy Telephone No. v <br /> (Property Location/A cess <br /> Property Own _ Address <br /> L Operator's Name 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 ❑ 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 /> Z. HOUSING <br /> ❑ HOTEUMOTEL/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 /> /. 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 /> Watre�rL�$upply Source Animal Waste Disposal Method <br /> a. 1XCONSULTATION FEE LlJ'b/C% BUSINESS LICENSE <br /> T. p PLAN CHECKING FEE ❑ DANCE PERMIT <br /> S. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ Sample 13 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 th application d that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,/and les and reg tion of th an Jo ui ocal Health District. <br /> APPLICANTS SIGNATURE Title Date ?^ 4--g <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received!By January 31 ❑ July 1 S Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE' $BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE C� � I <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER If CeIr <br /> 'a <br /> OTHER IS <br /> 0 <br /> 0 <br /> Received M Date 'SeMpt No. Permit No. luw 'Date Mailed Delivered i <br /> APPLIOANT—RETuaNJLL•com&To_ EE%00uMENTAL HfALTN PERMIT/MVWEe 1Nt E.NAglq4N AVE.,P.O.fee R STOCKTON,CA 95401 W <br />