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W <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure-To Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S ANO/OR <br /> APPLICANT'S AND/OR APPLICATION IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make __.-_—....... - <br /> BROKER ANDlOR Lic. No. _ <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,MOUSING <br /> REGISTRATION PUBLIC PODLS,WATER SAMPLING Regist. No.---- <br /> NUMBER <br /> o. -_NUMBER REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> r MISCELLANEOUS SERVICES <br /> Application Date_ _� �Q J_ Busin ss/Name To Appear On Permit <br /> bType Permit/Service�rRequest <br /> ad: <br /> Applicant Name /l/./��//�/ .� '40'.-r- i - ---- Address.. <br /> oike �-� 't s�C'L*�IGeBusiness Telephone�A_a,9 Emergency Telephone No. <br /> Property Location/Address �r>• , _ I�_�� /� mer/ 1j <br /> i Property Owner „ ._Irf Ai ;4 <br /> Address <br /> L Operator's Name !7�" �-J'�Z -�'f/i' Address_ 5, C <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 /> F❑ 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 (QO� <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED(Connections) OdE <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL 1:1SPA 13WADING POOL ElNATURAL BATH N <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 i <br /> S. CONSULTATION FEE . 00 ❑ BUSINESS LICENSE <br /> 7. PLAN CHECKING FEE 3r Oa ❑ DANCE PERMIT <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ Sampler-3 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 /> 1 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 rules and regulate of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X Title�� ' I Date -- <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 d Received By January 31 ❑ July 1 B Received By July 31 <br /> LINREMITTANCE $ REMIT <br /> %;I)ATEG <br /> EXPLANATION AMOUNT DUE CHECKED <br /> GATE REMITTED <br /> FEE AMOUNT <br /> LESS <br /> 0.00 O� <br /> PRORATION - <br /> PLUS � SERVICE SALES AMO MAINTENANCE <br /> TANK TRUCKS•BULK PLANTS•SERVICE STATIONS <br /> PENALTY LUBE EQUIPMENT-GAS PUMPS•METERS <br /> OTHER •VAPOR RECOVERY <br /> OTHER WESTERN 00 METER SERVICE, INC. <br /> • PETROLEUM EQUIPMENT <br /> Received by Date Receipt No. Permit No. l <br /> Issuance <br /> APPLICANT—RETURUALL.COUM ro: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.F/&+•• <br /> TEL.(209)948-6124 <br /> WILLIAM MESSICK 1531 EAST EIGHT MILE RD. <br /> LODI,CALIFORNIA 95240 <br />