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R <br />Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />hNGINEER'S <br />APPLICANT'S AND/OR ANDR <br />APPLICATION <br />CONTRACTOR AND/OR <br />BROKER AND/OR <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />LICENSE AND/OR <br />FOOD ESTABLISHMENTS, MOUSING <br />REGISTRATION <br />PUBLIC POOLS, WATER SAMPLING <br />NUMBER <br />REAL ESTATE INSPECTIONS <br />PO <br />GENERAL <br />IF VEHICLE INVOLVED, GIVE <br />Make <br />Lic. No. <br />Regist. No. __ <br />Color <br />ULTRY RANCHES AND KENNELS <br />MISCELLANEOUS SERVICES j <br />rApplication Date �?J _ B loess/Name To Ap ear On Permit U.J 2r <br />a Type Permit/Service Requested: . <br />Applicant Name_ Address0(0 <br />Busi Te ephone No. - ,a6-11— <br />Emergency Telephone No. <br />(Property Location/Address SII <br />Property Owner Address <br />L Operator's Name Address <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 />❑ HOTEUMOTEUNo. 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 />t. 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 />W r upply SourceAnimal Waste Disposal Method <br />B. CONSULTATION FEE ❑ BUSINESS LICENSE <br />7. ❑ PLAN CHECKING FEE -t:r katitm.vs ❑ DANCE PERMIT <br />B. 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 ws, and rules and regulations of the San Joaquin Local Health District. <br />APPLICANTS SIGNAT RE x `!<-�- r /� Title Date ,.�"6-ao <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 S Received By July 31 <br />BASE <br />EXPLANATION <br />BILLING <br />REMITTANCE <br />$ <br />AMOUNT DUE <br />REMIT <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEE 3,$ <br />g <br />$35.00 <br />x <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />Rec;�vy vme eeceipl No. Period No. Issuance Date Mailed Delivered <br />11501 E. HAZELTON AVE., P.O. Bea 2U09 STOCKTON, CA 915201 1 N <br />