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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 F000 ESTABLISHMENTS.HOUSING <br /> LICENSE AND/ORRegist. NO <br /> REGISTRATIONINSP . <br /> PUBLIC POOLS WATER SAMPLING <br /> REAL ESTATE COIOf <br /> NUMBER POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> rApplication Dale BIusiness/Name To Appear On Permit <br /> Type Permit/Service Requested: 1 dptrlpLT0ti rL flt1Xj_A — N'kbb I� <br /> Applicant Name sn JfYE ratr inn - Address f/.2Sin -- <br /> __Business Telephone No. L Emergency p �74�66 <br /> �� .�.J,,1 �� Emer enc Tele hone No.��-- <br /> Propeoy Location/Address 2 (� 0 y 0 I-=>�r <br /> iProperty Owner 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 110 <br /> � <br /> 2. HOUSING \ <br /> ❑ HOTEUMOTEUNo.of Units ❑ CERTIFICATE OF OCCUPANCY /\ <br /> ❑ MOBILE HOME PARK/No.of Spaces ` <br /> 3. WATER QUALITY ❑ WATER SAMPLE(Bacterial) <br /> ❑ ❑ CHEMICAL ` � <br /> PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY EI WATER HAULER 1 I y <br /> NO. OF PUBLIC SERVED(Connections) / <br /> E. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLAC <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds <br /> ❑ KENNEURunways /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> �ter Supply Source Animal Waste Disposal Method <br /> SC-CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> B. 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 �EA <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with Sen Joaquin County <br /> ordinances,state laws, and ru and regulatto I the n Joaquin Local Health District. <br /> APPLICANTS SIGNATURE X� � 41 Title Date <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 Recened By July 31 <br /> BILLING REMITTANCE' $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEELESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Aro to -fo-sss <br /> Rec by DaN Receipt No. Permll No. Issuance Date Mailed DNivsrad Z <br /> APPLICANT—RETUMALL CAMEaTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Baa NO STOCKTON.CA 0881 J <br />