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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/ORMake— -- <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Lic.NO. - - — <br /> BROKER AND/OR FOOD ESTABLISHMENTS.MOUSING <br /> LICENSE AND/OR PUBLIC POOLS.WATER SAMPLING Reglst. No.— <br /> REGISTRATION <br /> o.REGISTRATION REAL ESTATE INSPECTIONS Color --- <br /> NUMBER <br /> POULTRY RANCHES AND REMMEIE <br /> MISCELLANEOUS SERVICES FSCALON UNIFIED SCHOOL DISTRICT <br /> ('Application Date Q JUL 86 _— Business/Name To Appear On Permit <br /> •Type PermiLlService Requested: T> T Rennual <br /> Applicant Name R.cra l nn TTni f9 od. SChnol Di Stri CtA.ddress l S90 v Semi a Ave...PESS'l ans.SA__ 9,3 0 <br /> _Business Telephone No. 209 838-3591 Emergency Telephone No. <br /> (Property Location/Address69o1 S Jack Tone Rd Stkn Ca & 21051E Hwv 120. Escalona Ca. <br /> ',Property owner Fscalon Unified School District Address 1520 YOSeMITe AV*, Escalona Ca. 95320 <br /> `Operator's NameM(Connections�- <br /> 4. <br /> Address <br /> 1. FOOD ESTANTS Total Building SO. Footage Restaurant,McXimum Seating Capacity <br /> ❑ RESTAURANFOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCPL NT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FTAND ❑ LIp7UOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIOTORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MAES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROPESTING/No.of Id Employees <br /> ALL APPLICANTtal Employees Incl Ing Operators <br /> 2. HOUSING <br /> ❑ HOTEUMOT .of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOMK/No.of Spaces <br /> 3. WATER QUA ❑ WATER SAMPLE(Bact 'at) ❑ CHEMICAL <br /> ❑ PUBLIC WATSTEM ❑ SURFACE WATER PPLV ❑ WATER HAULER <br /> NO. OF PUBLICED(Connections) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ s;F ❑ WADING POOL 11NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL 13POULTRY FARM/Maximum No. Birds <br /> 13KENNEURunwaya /Animal Population No. No.of Confining Cages — <br /> Sewage Disposal Method - <br /> Solid Waste Disposal Method <br /> Water Supply Source Ani 1 Waste Disposal Method <br /> B. ❑ CONSULTATION FEE ❑ BUSIN S LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE MIT <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 th aappplication and that thy work will be done in a rdance with San Joaquin County <br /> ordinances, state laws,an rule and r 4'o soft uin Local Health District. <br /> X APPLICANT'S SIGNATURE X ^+ � Titta T Data 9 Jul 86 <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 37 <br /> BILLING REMITTANCE f REMIT <br /> BASE EXPLANATION AMOUN UE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Recelved by Dale Racelpt No. Permit No. IMuance Data Mailed Delivered i <br /> APPLICANT—RETUaN rOa TO: E ffi NMENTAL HEALTH PERMITMAVICES teat E.HA ELTON AYE.,P.O.sea Each STOCKTdI,G aM1 w <br />