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Applications Will Be Pro d When Submitted Properly Completed.14T <br /> Sign The Application. <br /> JOAQUIN LOCAL HEALTH GENERAL <br /> APPLICATION IF VEHICLE INVOLVED, GIVE <br /> ENGINEER'S AND/OR Make — - — -- <br /> APPLICANT'S AND/OR <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT ERVICE Lic. No. - -- <br /> BROKER AND/OR FOOD ESTABLISHMENTS,HOUSI Regist. No.----- <br /> LICENSE <br /> o. - --LICENSE AND/OR PUBLIC POOLS.WATER SAMPL <br /> REGISTRATION REAL ESTATE INSPECTIONS Color -- <br /> NUMBER POULTRY NEOUSE3 AND IS S <br /> MISCELLANEOUS SERVICES <br /> [Application Date Business/Nam o Appea On rmit <br /> ,Type Permit/Service Re uest d: � (( _ <br /> 1- �� Address. � ✓ (o <br /> iApplicant Name ,���p -� Emergency Telephone No. <br /> � Z' <br /> v Busin ss telephone No.— <br /> �Property Location/Address d � <br /> i Property Owner <br /> -yAddress�„ Address <br /> L Operator's Name <br /> +✓ 'F `� <br /> Total Building S Footage Restaurant, Maximum Seating Capacity <br /> 1. FOOD ESTABLISHMENTS g q' g ❑ MEAT MARKET <br /> Q RESTAURANT El FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE <br /> ❑ <br /> 11 ICE PLANT BAKERY <br /> C3 FOOD PROCESSING PLANT ❑ COMMISSARY ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ ROADSIDE FOOD STAND 11 LIQUOR STORE ❑ FOOD VENDOR <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION <br /> ❑ WENDING MACHINES/No. of <br /> ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ HOTEL/MOTEVNo. of Units <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY 1:1 WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> 13PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY 13 WATER HAULER <br /> NO, OF PUBLIC SERVED (Connections) ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL <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 /> Animal Waste Disposal Method <br /> Water Supply Source <br /> 13B. CONSULTATION FEE BUSINESS LICENSE DANCE PERMIT <br /> T. PLAN CHECKING FEE <br /> ❑ <br /> e. REAL ESTATE <br /> REQUEST: Water Well Inspection[] Sample[3 Title Company <br /> Sewage System Inspection ❑ <br /> 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 re lotions of the San Joaquin Local Health District. <br /> E �•� �' <br /> Title fiL- ►16ate — <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> F;! If Dui: ❑ ANNUALLY ❑ PER UNIT © PER SITE b EACH ❑ January 1 &Received By January 31 E] July 1 &Received By July 31 <br /> REMIT <br /> N BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Date Permit No. Issua 1a Maked Delivered <br /> '' <br /> Received by 1801 E.F. AVE.,P.O.Box 21109 STOCKTON,CA 95'201 <br /> w <br /> APPLICANT—RETILUM L L C;OPJES,TLL ENu1R AL REALTY{PERMIT/SERVICES <br />