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y 4 <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S ANO/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br /> BROKER AND/OR Lid.NO. <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> REGISTRATION PUBLIC POOLS WATER SAMPLING Regist. NO. _ <br /> NUMBER REAL ESTATE INSPECTIONS - Color <br /> POULTRY RANCHES AND KENNELS <br /> 3 //f/ MISCELLANEOUS SERVICES <br /> FApplication Date CY Bu iness/N-arn QApear On Permit <br /> wType Permit/Service Req este ��p`�l�f' <br /> Applicant Name J�Z Address <br /> ,ry Bu;i ells Tel phone NoEmergency Telephone No. 95�X_6�2y <br /> Property Location/Address a ®`�� <br /> d Property Owner �� /Ld- Address Z f 3�7 <br /> L Operator's Name Address f40W Az <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 /> 8. ji�CONSULTATION FEE--1_ 1 ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> 8. 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,and las and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X _ Title Date 3 -071 — �V <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 a Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION GATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE �QO <br /> LESS V <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �n <br /> Received by Date Receipt No. Permit No. in.ance Date Meilen Delivere0 i <br /> 11—APPLICANT—RETLaNJ COR1E&M ENVIRONMENTAL HEALTH PERMIT/SERWCES 1801 E.HAZELTON AVE.,P.O.aov Y008 STOCKTON.CA 96Z01 1W <br />