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•-std , <br />Applications Will Be Prw When Submitted Property Completed_ Be Surlegn The Application. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br />ENO INFERS ANDIOR <br />APPLICANTS AND/OR <br />CONTRACTOR AND/OR <br />BROKER ANDIOR <br />LICENSE AND/OR <br />REGISTRATION <br />NUMBER <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />1000 ETTA ItIENIrEIrTtt. MOUSING <br />FURLIC PDOLS, WATER SAMPLING <br />REAL ESTATE INSI'MTIONS <br />POULTRT RANCHES AND KENNELS <br />IF VEHICLE INVOLVED, GIVE <br />Make <br />Lid. No. <br />Regist. No -- <br />Color <br />jT NISCELLANEOUS SERVICES - 1l <br />rAPpllcation Date s / " f?6 Business/Nam To Appear On Permit '� �' ��yk t) jiL! H YE^I F� ck }�gy r) <br />r —�- <br />rType :s: ► Permit/Se`i nrice Requested: 11rt �r 1, .► w+ S ►^aCie - e� tE 1 ►Y/ t' ! ' f <br />Applicant Name / - Address '/11 /! st/7 wcti, <br />_ Business Telephone No. Emergency Telephone No. <br />Property Location/Address U ' "/ <br />Property Owner 5 S . _r- ] !? Address err R4&- er$ .41.,x:/ .0 <br />L Operator's Name '1 Address p <br />1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br />L❑ 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 />❑ HOTEUMOTEUNo. of Units ❑ CERTIFICATE OF OCCUPANCY <br />❑ MOBILE HOME PARKfNo. of Spaces <br />I 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 Y <br />S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No, of Birds <br />❑ KENNEL/Runways /Animal Population No. No. of Confining Cages <br />Com....... ni.rvn..I LIotF„v1 <br />Water Supply Source Animal Waste Disposal Method <br />❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br />T.PLAN CHECKING FEE s %` C'�'� 11 DANCE PERMIT <br />• 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 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 regulations of the San J Local Health District. <br />APPLICANTS SIGNATURE ii Title ALG / Gs'QGwl' taate <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 16 Received By January 31 ❑ Juty 1 i Rece,ved By July 71 <br />REMIT <br />BASE EXPLANATION BILLING REMITTANCE'AMOUNT DUE <br />DATE DATE REMITTED <br />CHECKED <br />AMOUNT <br />FEE <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />�r <br />s ✓� %� C `�C�li t <br />f <br />',F' Ci i2 <br />OTHER <br />/ �7 <br />Rack4ed I]y Date Roca -pt No- Perm,1 Na. Issuance tate Mailed Delivered <br />_ ... _ _-._.._ --. ��...�.�...� ... _,.��....�..�... ....... �... wr.....r,r r......•r. �rw. r u.ir, Y.su �v. .Ir ...� v,ar .YP,Kf11Y r'■ K]e1 <br />