Laserfiche WebLink
Applications WIII 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/OR <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br /> BROKER AND/OR LIC. NO. —— <br /> LICENSE AND/OR FOOD ESTABLISHMENTS.HOUSING Regist. NO. <br /> REGISTRATION PUBLIC POOLS.WATER SAMPLING 9 <br /> NUMBER REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> rApplication Date Business/Name To Appear On Permit _— <br /> eType Permit/Servicetn-TRegdealtPd�: <br /> e Applicant NOma T7�- "" ' r 1 `4 U "�. dress ` D __ <br /> u <br /> _ BSiness el ne — rge <br /> ency Telephone Noail <br /> . <br /> Property Location/Address y <br /> Jj Property Owner TC_ O c��o-, tovoen _ Address V C <br /> L Operator's Name Address <br /> /. 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 0 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 /> ❑ 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 /> 0. 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 /> Waterer Supply Source I _ Animal Waste Disposal Method <br /> S. 10 CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ Sample 13 Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <br /> Escrow No. <br /> Seller Seller Address <br /> Telephone No. Seiler 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, VRd rur Iey�egulatl�San Joaquin Local H � District. <br /> APPLICANT'S SIGNATURE X —hl _ Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 0 ANNUALLY ❑ PER UNIT 0 PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE' $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> in AMOUNT <br /> FEE sr� Js <br /> LESS <br /> PRORATIONPLUS <br /> PENALTY �( <br /> OTHER <br /> OTHER <br /> J o <br /> eceived by Dale Receipt No Germs No Issuance Date Mailed Delivered Z <br /> APPLICANT—RETYa6J1LL.Me el'TO. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 25201 N <br />