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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 <br /> APPLICANT'S AND/OR APPLICATION IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br /> BROKER AND/OR Lic. No. <br /> LICENSE AND/OR F000 ESTABLISHMENTS,HOUSING -- _---- <br /> REGISTRATION PUILIC POOLS WATER SAMPLING Regist. No.-- <br /> NUMBER REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> _�9—U`S� MISCELLANEOUS SERVICES <br /> [Application Date <br /> Bus' ess/Name To Appear qn P <br /> aType Permit/Service/B�aq�ueste/d� <br /> Applicant Name ��L W / Z.) C/, Atldress D <br /> /Busin$ss,T�lephyne No. Emergency Telephone No. <br /> Property Location/ res$ L. �__/�Q• t+�"U�i• <br /> i Property Owner �G—V5?El <br /> l�e 1,1, I ,� 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 /> ❑ HOTEUMOTEUNo.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 /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. 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 /> Water Supply Source Animal Waste Disposal Method <br /> S. 0 CONSULTATION FEE BUSINESS LICENSE <br /> T. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> S. 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 regulations of the San Joaquin Local Healistrict. <br /> APPLICANTS SIGNATURE X l �.�L �/�� -�L-ilirw-h /v _ Title Date q—/ Q L <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 31 <br /> BILLING REMITTANCE j REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNTDUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS / <br /> PENALTY ,,,�JJ � <br /> OTHER W .SS 0 iS 1 <br /> a <br /> OTHER <br /> Received by Date Receipt No. Permit No. lesuance Date Mailed Delivered `? <br /> APPLICANT—RETURNILL.GOaIEBTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1W1 E.NAZELTON AVE.,P.O.Bar 2001 STOCKTOH,CA 95201 <br /> W <br />