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f <br /> r <br /> 1 <br /> Applications WIII Beessed When Submitted Property Completed. Be Sut€To Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR Make----.---- <br /> CONTRACTOR <br /> ake -- — -CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> BROKER AND/OR Lic. No. -- ----- <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,HOUSING Regist. No. - <br /> REGISTRATION PUBLIC POOLS.WATER SAMPLING <br /> NUMBER REAL ESTATE INSPECTIONS Color - <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> �Appiication Date —b-e-Zi_`(�j6,�1—,,� Business/Name To Appear On Permit - <br /> r,Type Permit/Service Requested 1L�Lll1fl A� U�_�?I!� /Cat,�t>C <br /> Applicant Name `JI t��F�L +�& -- Address. �f7 ��I�lLU �Ui I _ - <br /> � _ Business <br /> ►CTelephone No _'i- �mer eneY Telephonehone No. <br /> Property Location/Address Aon --s-ax �r <br /> Property Owner �_fhiSi'Y1L�`1♦ _--���SC�I� _ Address <br /> L Operator's Name `i ��' �—r5 /_.1 3'at?l Address --__ -- - 5 ' <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 T ❑ MOBILE FOOD PREP UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees T <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 /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> ❑ KENNEL/Runways _ /Animal Papulation No. _ No.of Confining Cages <br /> Sewage Disposal Method - <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> 6. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE — <br /> 7. ❑ PLAN CHECKING FEE _ ❑ DANCE PERMIT <br /> 6. 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 /> 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 Joaquin Local Health District. <br /> c r <br /> APPLICANT'S SIGNATURE X ' _ Title ' Date _ d . <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE ExPLANATION BILLING REMITTANCE' $ AMOUNT DUE CHECKED <br /> DATE DATE rv-REMITTED AMOUNT <br /> �' LitJ FV '+ <br /> FEE O <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> a <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered = <br /> APPLICANT—RET.UAM.ALLCOBIES.TO, ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HATELTON AVE.,P.O.Box 2604 STOCKTON,CA 05441 w <br /> IM Y V <br />