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• Applications Will Be Processed When Submitted PLdperly Completed. Be Sure To Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR <br /> APPLICANTS AND/OR APPLICATION IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make. <br /> BROKER AND/OR Lic. No. <br /> --.-- <br /> LICENSE ANO/OR F000 ESTABLISHMENTS.HOUSING <br /> REGISTRATION PUBLIC POOLS,WATER SAMPLING Regist. NO. <br /> NUMBER REAL ESTATE INSPECTIONS Color— <br /> POULTRY RANCHES AND KENNELS - --- <br /> MISCELLANEOUS SERVICES <br /> FApplication Date zo —� I _ Bu iness/Na To A ear On Permit <br /> pType Permit/Service Vested: <br /> Applicant Name Addressk7^ <br /> BWsin s Tel phone No. rgency Telephone No. — <br /> PropertyLocation/Aresg —�60/r /i <br /> i Property Owner G ti k 2 k4 I '$ _ Address ' H <br /> L Operator's NampZ7 <br /> 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 /> Z. HOUSING <br /> ❑ HOTEUMOTEL/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 11 SURFACE WATER SUPPLY 13 WATER HAULER <br /> NO.OF PUBLIC SERVED (Connections) <br /> e. •RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5? VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds . 1i <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. CONSULTATION FEE .aJC% 13 BUSINESS LICENSE <br /> 7. PLAN CHECKING FEE ❑ DANCE PERMIT <br /> S. 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 <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,�//d/1 rule aann/d regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ��i.Y' I�/ ��- __ Title O� 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 R Received By July 31 <br /> BILLING REMITTANCE s REMIT <br /> GAGE EXPLANATION DATE DATE REMITTED AMOUNT OUE CHECKED <br /> y AMOUNT <br /> FEE 35.0D <br /> LESS c� <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER / y <br /> OTHER <br /> Received Oy Dale Receipt No. Permit No. - Issuance Oete Mailed Delivered o <br /> I <br /> APPLICANT—PETLIaN4LCOR1E4TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.H42ELTON 4VE..P.O.aos 100a STOCKTON,CA BS]Ot m <br />