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Applications Will Be ProZ`essed When Submitted Properly Completed. Be Sullo Sign The Application. <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR Make -- <br /> CONTRACTOR ANO/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 /> L MISCELLANEOUS SERVICES <br /> Application Date G b Business/Name To Appear On Pe-.1 ----- <br /> wType Permit/Service ested: fjJ�Y1/A 2"/OBBd;� �j_�y� <br /> Applicant Name Address 'f7�U �pw ni'f-7—a '—G1cc 6d[�_5 — <br /> r��l /O a __ S1 •s Telephone No. 3 dA AD B Emergency Telephone No. <br /> Property Locati n/Address Ll e�a 'r•' __ <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 /> ❑ HOTEUMOTEL/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 Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> S. CONSULTATION FEE S'00 ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE _ ❑ DANCE PERMIT <br /> S. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample 13 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, rules and regulations of the San Joaquin Local Health District. <br /> APPLICANTS SIGNATURE _ Title Date 3 <br /> ARTMENT 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 /> BILLING REMITTANCE $ REMIT <br /> BASE - EXPLANATION DATE DATE REMITTED AMOUNT DUE CAMOUNT <br /> CHECKED <br /> FEE Go .rg6� od <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY Cly O S <br /> OTHER <br /> 'a <br /> OTHER <br /> 0 <br /> Received by Date Receipt No Permit No Issuance Date Mailed Delivered Z <br /> APPLICANT—RETUANLL COPJESTO. ENVIRONMENTAL HEALTH PERMIT/SERVICES 16111 E.HASELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201 W <br />