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� <br /> Applications Will Be Processed When Submitted Properly CbmUpJleted. Be S re To Sign T Adp <br /> llutli <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTE2��q` i <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 ANO/OR LIC. NO. <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,HOUSING '— <br /> REGISTRATION PUBLIC POOLE,WATER SAMPLING Regist. NO. <br /> NUMBER REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS - <br /> MISCELLAMEDUS SERVICES <br /> rApplication Date Business/ time To ppear On Permit_�' J ✓��f�(/X C� ��• <br /> Type Permit/Service Requested: L- ��(/.1 <br /> Applicant Name--'ikl ��• r 4K199 i ( 'O -TAAcldress J2 S 41 0 -- <br /> Business Telep ne No.4K /sf37 Emergency Telephone No. <br /> Property Location/Address ✓y6 9'8I <br /> ProS <br /> 'Property Owner 4 V Address _ <br /> L Operator's Name /I r r 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 ❑ M0131LE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No.of Field Employees �l <br /> ALL APPLICANTS: Total Employees Including Operators �n- <br /> 2. HOUSING <br /> ❑ HOTEUMOTEUNo. of Units ❑ CERTIFICATE OF OCCUPANCY 16—MAJI� <br /> ❑ MOBILE HOME PARK/No. of Spaces �n ry C) <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER f `L� _ y� <br /> NO.OF PUBLIC SERVED (Connections) 1V�L/—`/Ih <br /> s. RECREATIONAL HEALTH ❑ SWIMMING POOL 13 SPA 13 WADING POOL 13 NATURAL BATHING PLACE- y <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds YV(bw..,L".t, . <br /> ❑ KENNEL/Runways /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method yn <br /> Solid Waste Disposal Method <br /> Water Sopply Source Animal Waste Disposal Method <br /> S. 110 CONSULTATION FEE .3 ❑ BUSINESS LICENSE _ <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> R. REAL ESTATE b / � <br /> REQUEST: Water Well Inspection❑ Sample❑ Title Company <br /> Sewage System Inspection ❑ Address <br /> Tele. No. <br /> Escrow No. 'HT1 <br /> Seller Seller Address <br /> Telephone No. Seller Agent Name �d°v� <br /> Service Request For Date <br /> I hereby Certify that 1 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. / rJ c� <br /> APPLICANTS SIGNATURE Title 0 r^'� Date E b <br /> FOR DEPARTMENT USE ONLY <br /> Fee ID Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 E Received By January 31 ❑ July t S Receives By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> J AMOUNT <br /> FEE ;y. 3S do <br /> LESS - — <br /> PRORATION <br /> PLUS -- <br /> PENALTY <br /> OTHER <br /> OTHER <br /> i� 9-9-rS <br /> Received by Date Fiecespi No. Permit No. Issuance tate Me11e DMI. d <br /> APPLICANT-RETIIBNJMA.CpaMt TO: EMYaIONYlNTAL HEALTH PERYIT/5lRV1Cl6 101 E.1M2ELTON AVE.,P.O.sea 1006 eTOCKTON,CA YFZat <br />