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Appllcaflonsi Will 8e Processed When Submitted Property Completed.8a Sura To Sign The Application, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT .GENERAL <br /> ENGINEERS AND/OR <br /> APPLICANT'SNTSAND//OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> AN <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make _— <br /> BROKER AND/OR LIC.NO. <br /> LICENSE AND/OR FOOD ESTABUSNMENTS,MOUSING - <br /> REGISTRATION PUBLIC POOLS,WATER SAMPLING Regist:NO. _ <br /> NUMBER REAL ESTATE INSPECTIONS Color _ <br /> POULTRY RANCHES AND KENNELS4r-0 _ <br /> MISCELLANEGUB Sgy10Es <br /> rApplication Data <br /> ��> Business/yame To ear On Permit ' �""'� °��-'�"" ✓ J— �' <br /> Type Permit/Service Requested: �'• r>r <br /> Applicant Name �tZif7iif f-.�-3is-Addreaa- //? S A --- <br /> -� ._ Business Telep�Qne No. .�T/- /¢';7 Emerge cy Telephone No. JW 9 �� 9 <br /> Property Location/Address /.SGrfr�r/ l�Ll�ie"/..0 / <br /> Property Owner n v _ Address <br /> L Operator's Name /' I ' Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Sealing 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 /> ❑ HOTEVMOTEVNo.of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces <br /> J. WATER QUALITY ❑ WATER SAMPLE(Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER 'gf"MA^t\rt <br /> NO.OF PUBLIC SERVED (Connections) <br /> A. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> ❑ KENNEVRunways /Animal Population No. No.of Confining Cages O <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water pply Source Animal Waste Disposal Method <br /> S. CONSULTATION FEE BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ Sample❑ Title Company e't�vL <br /> Sewage System Inspection ❑ Address Tele. No. <br /> Escrow No. r (� <br /> Seller Seller Address [NAW�dC� <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 /> APPLICANTS SIGNATURE Title {` ) <br /> _ .tAti/ Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY (3 PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 71 ❑ July 1 A Received By July 61 <br /> BILLING REMITTANCE s REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE l <br /> _„ oo <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTYy' <br /> OTHER <br /> OTHER <br /> M) <br /> Flocervact by Dan Racaipl No. Permit No. laauanca Dale M read DNWared ?_ <br /> APKIC.VIT-R[TMWJ1lLfJ]aIEa TO: ENVIRONMENTAL HEALTH PERMITr1ERwO ,. <br /> a m�e ..........-- ---_._ __ -- _- <br />