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Applications Will Be Assad When Submitted Properly Completed. Be SurAvSign The Application. <br /> ENGINEER'S AND/OR SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> APPLICANTS AND/OR APPLICATION IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR BROKER AND/OR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br /> COOTER AND/OR - -- <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,MOUSING Lie. NO. _ <br /> REGISTRATION PUBLIC POOLS WATER SAMPLING Regist No. <br /> NUMBER g <br /> REAL ESTATE AND KE Color <br /> POULTRY RANCHESCHES AND KERNELS <br /> [Application Date .9 <br /> /b MISCELLANEOUS SERVICES _ <br /> Busify�ss,/��iam��jjTo��lppppear Oy <br /> •Type Permit/Service Rfqua ted' //1 ttrLT�07c (/ 000 -- <br /> 7C Applicant Name IJ/ 'f �R �//��, 4,�.• Ad ress <br /> u - [I/O <br /> Business Tephone Nor�� / Emergency Telephone No.� Oq �C�Zy <br /> Property Loc; s GdIA�T/.1 /P4 <br /> -1Property Owner <br /> Address <br /> I Operator's Name It ry <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 /> 2. HOUSING <br /> ❑ HOTEL/MOTEVNo. 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 /> 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 /> Water Supply Source Animal Waste Disposal Method <br /> 6. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. PLAN CHECKING FEE71� __ ❑ DANCE PERMIT <br /> B. REAL ESTATE ' �!J' 'Uv <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 Health District. <br /> APPLICANT'S SIGNATURE X _ Title 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 8 Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNTDUE CHECKED <br /> FEE AMOUNT <br /> LESS _ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I ,` ��13i Fs �13c o <br /> Received Dy Date Rece,pt No. P li No. Issuance Date Mailed Delivered <br /> APPLICANT—RETLI ALLCORIEa TO: ENVIRONMENTAL HEALTH PERM R /`Eg 1801 E.HAZELTON AVE.,P.O.Bos p00p STOCKTON.CA asfol iv <br />