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Applications Will Ba PrOCasaW When Submitted Properly Completed, Be Sura To Sign The Application. <br /> ENIPUNSAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> C <br /> APVLEANT'S AND/EMS OOR APPLICATION IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br /> BROKER AND/OR <br /> LICENSE AND/OR Fe"EAAKMEUT&HOIms LiC. No.REGISTR <br /> NUMBER 394241 <br /> 394241 PUBLIC-MK&WATER SAMRLKEL Regist. No. <br /> REAL ESTATE ISAPECTWNA COIOf <br /> POULTRY RANCHES AND KENNELS -- — - <br /> MISCELLANEOUS SERVICES <br /> rApplication Date 1-6-$7 Business/Name To Appear On Permit _ Je=v Joy and Associates <br /> *Type Permit/Service Requested: Under onna fit 1 C: orag—_r Tal <br /> Applicant Name Tarry jbTr c AGGa.ia}-pC Address 1000 N Union Strppt <br /> _ Business Telephone No. 462-1481 Emergency Telephone No. 462-1481 <br /> (Property Location/Address 3736 S Hight ,y qq J, q} >, atr r, Tjfr1�X7Aja <br /> I Property Owner _ grwk Rro h rs Address 3736 S. Highuray 99 <br /> I Operator's Name Rrwk RrnthprS Address 3736 S. Hi Oh4>aV 99 <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/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER DUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <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 /> ❑ 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 /> a. ❑ CONSULTATION FEE ❑ 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 /> y 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 ulations of the San Joaquin Local Health District. <br /> APPLICANTS SIG E Titla�r",_ r.1,� Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee to Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I A Rw*Kvd By Janwry 31 ❑ July I a Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> BASE E%PLANATION S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PL <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Rece.ed DY Dne RsuiP1 No Permit No. Inwnce DaN Mailed Delivered o <br /> APPLICA/R—NETWNALLCOaIEl TO: ENVIRONMENTAL.HEALTH PE MMIBERVICES tact G HAEELTON AYE.,P.O.ata Well tTOCI(TON.CA taAl <br />