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Applications WIII Be ProNed When Submitted Properly Completed. Be Sureesign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <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 AND/OR LiC. NO. <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,HOUSING -- <br /> + REGISTRATION PUBLIC POOLS.WATER SAMPLING Reglst. No. <br /> NUMBER REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS — <br /> MISCELLANEOUS SERVICES <br /> rApplication Date — (6(o MISCELLANEOUS <br /> To Appear On Permit San aoh b CA Q P <br /> a Type Permit/Service Requested: L� L `1.^ 11041AGA-I„ I- U%Y-,�V, <br /> Applicant Name �BtE i0 tl CCAF1. _ q dress— •Q S•Rrr1L,-ic.LcaN ? f 7F�FJ\cS <br /> p <br /> ._ Business Telephone No. 46 0.1•IS j. Emergency Telephone ryB <br /> Property Location/Address `1'F'l+'l+ A)- Hk.)Y 9 u.� _ mac jr- 93R-5334 ( id r64" <br /> :Property Owner Ciao&)a •$, S � (��� �J, LDIVI q., 9V5R. <br /> s ^ Address Z EWAI(}E1C-iT_. �A/ Ci+hJ � <br /> L Operator's Namey�_O&W •U'N-R• R- Address z Anled A'o,G7L &Af SA nl 4" w Gi 4gS-,8 <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 /> ❑ HOTEL/MOTEL/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 ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED(Connections) <br /> 9. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. 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 /> S. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> S. REAL ESTATE <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 certity, 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 T/i�ta V Date 7^ at-86 <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 6 Received By January 31 ❑ July 1 S Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE S REMIT <br /> GATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 7 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7-3-$10 <br /> Recenea by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETl1 ALL CONUTO: ENVULONMENTAL HEALTH PERMIT/SERVICES last E.HAZELTON AVE.,P.O.Be.9009 STOCKTON,CA 99401 W <br />