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Applications Will Be Promssed When Submitted Properly Completed. Be Sure 10 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 ReglSt. NO <br /> REGISTRATION PUBLIC POOLS.WATER SAMPLING <br /> NUMBER REAL ESTATE INSPECTIONS Color — <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> FApplicalion Date 5,11d11S _ Business/Name T.o,V�Appear On Permit ��Ir FPeD Coni - <br /> ---- <br /> TypePermiVSennCeRequested: LA R'iz aeM 1Jo / 7yVk d-R'W10 V9L 0 <br /> Applicant Name TORN tM✓E•Lr d6 f sTLE Feea ceap )Address <br /> 4 _— Business Telephone No. Zd9 9Y I 001 Emergency Telephone No. — <br /> Property Location/Address 230 /N0US-rA14L., At/E. /QEP9 �J4 <br /> i Property Owner NfJ7LE' reels ce^P. Address 230 /ND✓s 7'K/?L *Wr <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 /> ❑ 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 /> 5. 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. .Lt CONSULTATION FEE BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE DANCE PERMIT <br /> St. REAL ESTATE 7 26oA"/�,, � V- <br /> �C <br /> REQUEST: Water Well Inspection CI Sample❑ Title Company "A <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 /> APPLICANTS SIGNATURE X a _ Title POW-rNG//✓rfIC Date 5/1114a <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is DI ❑ ANNUALLY (3 PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 S Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE REMIT <br /> S AMOUNT DUE CHECKED <br /> GATE DATE �RjE.M.I�T/TED AMOUNT <br /> FEE 3s JU <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER W F <br /> OTHER <br /> AV S-la�S <br /> Received by Dete Receipt No. Permd No Issuance Date Mailed Delivered 1 <br /> APPLICANT—RETURN) CCUREILTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.lax NO STOCKTON.CA 25201 W <br />