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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ENGINEER'S AND/OR APPLICATION <br />APPLICANT'S AND/OR <br />CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />BROKER AND/OR <br />LICENSE AND/OR FOOD ESTABLISHMENTS, MOUSING <br />REGISTRATION( PUBLIC POOLS WATER SAMPLING <br />NUMBER c� i Lp i' REAL ESTATE INSPECTIONS <br />[Application Date-' — Busines;/Nan <br />to Type PermiVServic Re pasted: - <br />i ADDIic Lela _ <br />ji <br />r <br />Property Location/ dress <br />iProperty Owner <br />I Operator's Name <br />GENERAL <br />IF VEHICLE INVOLVED, GIVE <br />Lid. No. <br />Regist. <br />Color _ <br />POULTRYRANCHES AND KENNELSMISCELL <br />MISCELLANEOUS SERVICES % G— <br />To Appear On Permit <br />Address <br />Ip6gne No. Emerg@nyy Telephone No. <br />Address <br />Address <br />1. F000 ESTABLISHMENTS <br />Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br />C. R STAURANT ❑ FOOD <br />MARKET RETAIL <br />❑ FOOD MARKET WHOLESALE <br />❑ MEAT MARKET <br />FOOD PROCESSING PLANT <br />❑ COMMISSARY <br />❑ ICE PLANT <br />❑ BAKERY <br />ROADSIDE FOOD STAND <br />❑ LIQUOR STORE <br />❑ BAR <br />❑ ITINERANT RESTAURANT <br />❑ CONFECTIONARY STORE <br />❑ FOOD SALVAGER <br />❑ FOOD DEMONSTRATION <br />❑ FOOD VENDOR <br />❑ VENDING MACHINES/No. of <br />❑ MOBILE FOOD PREP. UNIT <br />❑ VENDING VEHICLE <br />❑ FOOD CROP HARVESTING/No. of Field Employees _ <br />ALL APPLICANTS: Total Employees Including Operators <br />Z. HOUSING <br />❑ HOTEL/MOTEL/No. of Units <br />❑ MOBILE HOME PARK/No. of Spaces <br />3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) <br />❑ CHEMICAL <br />❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br />❑ CERTIFICATE OF OCCUPANCY <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 <br />Sewage Disposal Method <br />Solid Waste Disposal Method <br />Water Supply Source <br />S. ❑ CONSULTATION FEE, <br />7. ❑ PLAN CHECKING FEE <br />/Animal Population No. <br />B. REAL ESTATE <br />REQUEST: Water Well Inspection❑ Sample❑ <br />Sewage System Inspection ❑ <br />Escrow No <br />Seller <br />Telephone No. <br />Service Request For Date <br />No. of Confining Cages <br />Animal Waste Disposal Method <br />❑ BUSINESS LICENSE <br />❑ DANCE PERMIT <br />Title Company <br />Address Tele, No. <br />Seller Address <br />Seller Agent Name <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 lawssS.aaann �.�{plate and re ti of the San Joaquin L Health District. L <br />001, <br />APPLICANT'S SIGNATURE /w�,7 T Tit' Date— gC/ r <br />FOR DEPARTMENT USE OWK <br />FAR Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I S Received By January St ❑ July 1 S Received By July 71 <br />REMIT <br />BABE <br />EXPLANATION <br />BILLING <br />REMITTANCE <br />S <br />AMOUNT DUE <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEE <br />�D <br />r <br />V <br />O . <br />PESS <br />RORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />Received by Dale Receipt No. Permit No. Issuance Date Mailed Delivered <br />•m, .1— —.1— Y Y[OYIT/![YVIf[C 1N1c Malcl T.. aVc Yn.—. 41MeTrve rJ YaM <br />