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Applications Will Be Processed When Submitted Properly Completed.Be Su.0 Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> IF VEHICLE INVOLVED,GIVE <br /> ENGINEER'S AND/OR APPLICATION Make -- <br /> APPLICANT'S AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Lic.No. <br /> CONTRACTOR AND/OR <br /> BROKER AND/OR FOOD(ESTABLISHMENTS.HOUSING Regist. No. — <br /> LICENSE AND/OR pUOLIC POOLS,WATER SAMPLING Color <br /> REGISTRATION REAL ESTATE INSPECTIONS <br /> NUMBER pOULTRT RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES ,l <br /> rApplication Date 1Z� <br /> �� Business/Name To Appear On Permit 0= /T' AVID ~i <br /> ,a Type permit/Service Requested: <br /> Address7— S-410 <br /> Applicant Name — Emergency Tel hone No.�" <br /> Business Telephone N 5?Tc gzn <br /> /Frc T GA. <br /> Property Location/Address Address q � � II <br /> dProperty Owner Address <br /> L Operator's Name7:%�k Restaurant,Maximum Seating Capacity <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage ❑ MEAT MARKET <br /> O RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ BAKERY <br /> ❑ FOOD PROCESSING PLANT [I COMMISSARY ❑ ICE PLANT <br /> ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> 13 ROADSIDE FOOD STAND ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ CONFECTIONARY STORE 11 FOOD SALVAGER 11 VENDING VEHICLE <br /> 13 VENDING MACHINES/No.of <br /> ❑ MOBILE FOOD PREP.UNIT <br /> ❑ FOOD CROP HARVESTING/No.of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ HOTEUMOTEUNo. of Units <br /> ❑ MOBILE HOME PARK/No,of Spaces ❑ CHEMICAL <br /> 13 PUBLIC WATER SYSTEM <br /> 3. WATER QUALITY ❑ WATER <br /> SURFACE WATER SUPPLY 11WATER HAULER <br /> NO. OF PUBLIC SERVED(Connections) ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds <br /> ❑ KENNEL/Runways <br /> /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Animal Waste Disposal Method <br /> Water Supply Source y. <br /> B. Ef CONSULTATION FEE ' ❑ BUSINESS LICENSE11 DANCE PERMIT <br /> 7. 11PLAN CHECKING FEE <br /> a. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample❑ Title Company <br /> Tele.No. <br /> Sewage System Inspection <br /> 13Address <br /> Escrow No. <br /> Seller Address <br /> Seller <br /> Telephone No. Seller Agent Name <br /> Service Request For Date <br /> I hereby certify that 1 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 <br /> s Title Date <br /> zeps—A <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 A Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE' s AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS 1� <br /> PRORATION <br /> PLUS 1�-ILA fi <br /> PENALTY <br /> OTHER m <br /> n <br /> OTHER <br /> 0 <br /> 0 <br /> Date <br /> Receipt No. Permit Nv. Issuance Date Mailed Delivered <br /> Received by Y <br /> CUla7E&!Q' ENVIRONMENTAL HEALTH PERMI!!$ERVICES <br /> 1[01 E.HAZELTON AYE.,P.O.aox 20MaTOCKlON,CA 1SY01 <br /> APPLICANT—RETURKALL• <br />