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Applications Will Be rrocessed When Submitted Properly Completed. Be Sure-1'SSign 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 /> coNT�ncroRAND/o� ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> `eRORER"xIVD76R— Lic. No. <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,MOUSING <br /> REGISTRATION / �j PUBLIC POOLS.WATER SAMPLING Regist. NO <br /> NUMBER F!L-7,9 5_7 _ _ __ REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> rApplication Date Business/Name To Appear On Permit _Lt�C LSLLTI,3 :Jjocn5^F`P.t-K/A . <br /> iType Permit/Service Requested: <br /> Applicant Name VO(Z<C-C^ Z>i�- Address Lc"{/ g ISI �r'S <br /> E —Business Telephone No. �Z317 4162 moi!/ Emergency Telephone NG <br /> PropertyLocationl4ddress 4�RL01L)e <br /> J Property Owner AJ COLA.J M I-ICD _ 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 /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/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 /> 4. 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 /> Wa er upply Source Animal Waste Disposal Method <br /> S. CONSULTATION FEE 13 BUSINESS LICENSE <br /> 7. PLAN CHECKING FEE ❑ DANCE PERMIT <br /> S. 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 rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X Title 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 A Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BABE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE FEE o OU✓ -1 q ENT <br /> WOEIVED <br /> LESS <br /> PRORATIONPLUS <br /> _ <br /> PENALTY _ SEP 9 1988 <br /> OTHER MC ( q EN <br /> LT <br /> OTHER PERMI <br /> r <br /> O <br /> Received by Dale Receipt No Permit No. Ieeuance Date Meilad Delivered 2 <br /> APPLICANT—RETUaNJW.nLelESTO: 'ONMENTAL HEALTH PERMIT/SERVICES 1a01 E.H TON AVE.,P.O.sor 20119 STOC KTON,CA:5001 al <br />