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• Applications Will Be&sed When Submitted Properly Completed. Be S'*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 AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES -- <br /> BROKER AND/OR LIC. N0. -- <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,MOUSING Regisl. No. <br /> REGISTRATION PUBLIC POOLS,WATER SAMPUNR <br /> NUMBER REAL ESTATE INSPECTIGNS Color <br /> POULTRY RANCHES AND KENNELS <br /> L MISCELLANEOUS SERVICES <br /> rApplication Date ✓ Business/Name To Ao---.Div Permi �T'i <br /> Type Permit/Service lz7cested: f1AN 2--lCOBO �` <br /> Applicant Name Address 'f 7eU <br /> w <br /> u_ <br /> C _ B si s Telephone No. `/6 S <br /> 6 tl Emergency Telephone No. <br /> Property Locati n/Address /'' <br /> Property Owner /,/.... l'I fv^ . 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 /> ❑ HOTEL/MOTEVNo.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) e <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 /> B. Ii CONSULTATION FEE S•00 ❑ 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,Rod rules and regulations of the San Joaquin Local Health District. <br /> 9 � 7 <br /> APPLICANT'S SIGNATURE _ Title Z57k __ fr{e-� Date -i <br /> PQR 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 /> REMIT <br /> BILLING REMITTANCE S <br /> BASE ' EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> [� AMOUNT <br /> FEE <br /> FEE �J i 00 <br /> LESS <br /> PRORATION <br /> PLUS r <br /> PENALTY G� <br /> OTHER /��,r• P ,fJ /&10 <br /> (/L" _ <br /> OTHER ^ <br /> Received by Date Receipt No Permit No. Issuance Date Malled Delivered 1 <br /> APPLICANT—RETOaNJ cLL gl c TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1x01 E HAZELTON AVE.,P.O.aaa 000a STOCKTON.CA 15101 w <br />