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Applications Will Be Pried When Submitted Property Completed. Be Sure Sign The Application. <br /> ` SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR <br /> APPLICANT'S AND/OR APPLICATION IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br /> BROKER AND/OR Lic. No. <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,HOUSING - <br /> REGISTRATfON PUBLIC POOLS,WATER SAMPLING Regist. No. <br /> REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> Application Date C l7ppear On Permit <br /> Business/Name To A <br /> w Type Permit/Service RequestedApplicant Name ✓ 'rte � d~i <br /> Address <br /> r .;iC <br /> -- �^ Business Te <br /> �� r <br /> lephone fvo.r ✓(�>r ,- :`1 Emergency Telephone No. — <br /> {Property Location/Address Yi . j ;) -. — <br /> Property OwnerKL,.) <br /> Address ,- <br /> 1 Operator's Name Address — <br /> f. -. <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/MOTEUNa. 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)w -_ <br /> <. 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 /> Water Supply Source -_._ _ _ _ Animal Waste Disposal Method <br /> B. ❑ CO LTATION FEE - - - - -❑ BUSINESS LICENSE <br /> 7. LAN CHECKING FEE -_L -T__-�d�S A F711r C1 DANCE PERMIT <br /> O. REAL. ESTATE <br /> REQUEST: Water Well Inspection❑ Sample❑ Title Company <br /> Sewage System Inspection ❑ Address _ Tele. No. <br /> Escrow No. _ ___ <br /> Seller - Seiler Address <br /> Telephone No. - Seller Agent Name <br /> Service Request For Date <br /> I hereby certify that I hav prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a rules and regulat' sof th an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X --- -- Title ` �+�f Date - <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUA LY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE:' $ REMIT <br /> BASE EXPLANATION <br /> GATE DATE REMITTED AMOUNT OUE CHECKEDAMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> //Date Receipt No Permit NaT o <br /> lssuence pate Meiletl Delivered _ <br /> APPLICANT—RETL NAJI_C-0P1ES.TO: EN*ENTAL HEALTH PERMITtSERVICES 11111011 F.HAZ*AVE.,P.O.Bos 2001 STOCKTON,CA 15201 <br /> w <br />