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Applications Will Be PruceaRad When Submitted Properly Completed. Be Sur Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEERS AND/OR APPLICATION IF VEHICLE INVOLVED, GIVE <br /> APPLICANTS AND/ORMake <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Lic. No. -- <br /> BROKER AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> LICENSE AND/OR PUOLIC POOLS WATER SAMPLING Regisl.NO. — <br /> REGISTRATION REAL ESTATE INSPECTIONS Color <br /> NUMBER POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> rApplication Date �Ls' Ju b Business/Name To Appear er O P 2 = <br /> Type Permit/Service Requested: AgAa 8 n�a <br /> Applicant Name Address <br /> _Business Telephone No. �ZQ— r�dp Emergency Telephone No. 4— a"t'2J <br /> Property Location/Ad ress <br /> Property 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 <br /> 2. HOUSING <br /> 13HOTEL/MOTEL/No. of Units 13 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 /> S. 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 /> W er Supply Source Animal Waste Disposal Method <br /> S.XCONSULTATION FE ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 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 this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rules and regijlafions of the San Joaquin Local Health District. <br /> APPLICANTS SIGNATU E X _ Title < <i Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 d Received By January 31 ❑ July 1 a Receiv REMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE' $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE t 1�� �0 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER — <br /> C lbs 4sto � " ?�a� <br /> Received by Dale Receipt No. <br /> 1/ Per issuance Date Mailed Deli led i <br /> APPLICANT—RETLBNAIi.nONMa70_ ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2ELTON AVE.,P.O.Bea EOOY BTOCKTON,CA 15301 <br />