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ENGINEER'S AND/OR <br />APPLICANTS AND/OR <br />CONTRACTOR AND/OR <br />BROKER AND/OR <br />LICENSE AND/OR <br />REGISTRATION <br />NUMBER <br />r <br />Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />SAPS JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />FOOD ESTABLISHMENTS. MOUSING <br />PUBLIC POOLS, WATER SAMPLING <br />REAL ESTATE INSPECTION3 <br />POULTRY RANCHES AND REMRELS <br />IF VEHICLE INVOLVED, GIVE <br />Make <br />Lid. No. <br />Regist. No. <br />Color <br />�_ MISCELLANEOUS SERVICES <br />rApplication Date sines-/IN-a-me�jo Appear On Per 't <br />11 Type Permit/Servi! R/�que ted: �✓r A FbC �i S 6lllii %OD(/ . 1Q - <br />Applicant Name �•'� �-s ..S A"ddress <br />us e e b No/w G Emergen y Telephone No ��'I <br />Property Location/Address...1V5'-r:W -i A �"' �y ••••^ y� <br />Property Owner ress oeo-a <br />Wperator's Name // y • Address rt <br />1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br />d 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 QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br />❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br />NO, OF PUBLIC SERVED (Connections) <br />4. 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 />C.m.n. nl.n-1 ".thud <br />cnuA wont. ni.nnaa L./.thnd <br />Water Supply SourceWaste Disposal Method <br />S. 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 />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 >kQd regulations of the San Joaquin Local Health District. <br />APPLICANT'S SIGNATURE X_/lj Title Dale <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Receives By January 31 ❑ July 1 S Receives By July 31 <br />REMIT <br />BILLING <br />BASE EXPLANATION <br />REMITTANCE <br />$ <br />AMOUNT DUE <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEE <br />U <br />0 <br />LESS <br />C� <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />Cx/mire 3y <br />Received by Dale Receipt No. _ Permit No. Issuance Date Mailed Delivered <br />.,.., u..... ....,...... nn.,cn.n. ...,....euro xeu rx..ar.. ineevx•ee um c ..". rnx avo o n Ir..: ivw smecrnu 'A aevel <br />