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1 Applications Will Be eased When Submitted Properly Completed.Be S#To Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION <br /> Make <br /> VEHICLE INVOLVED, GIVE <br /> APPLICANT's AND/OR M <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Lic. No. - ---- --- <br /> BROKER AND/OR FOOD EETA2LISHMENTS,HOUSING Regist. No. - --- <br /> LICENSE AND/OR PUNLIC POOLS.wATEN SAMPLING <br /> REGISTRATION HEAL ESTATE INSPECTIONS Color ----- <br /> NUMBER POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS tiERYrmit - <br /> !� .. - <br /> Applicatian Date �_ Business/Name To Appear On Permit <br /> 11 Type Permit/Servicd; <br /> TAddress[>- <br /> =u Applicant Name -� Emergency Telephone No. — <br /> _ B sines Tele-ptllon�e,N-oma -= ' L <br /> Property Location/Address14110 <br /> � L.coA�, C 5"L41� <br /> Property Owner P '! _. � _ - Address <br /> tAddress <br /> L Operator's Name - --- - - -- <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Seating Capacity <br /> 1:1 RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> 13 FOOD PROCESSING PLANT ❑ COMMISSARY Cl ICE PLANT 13 BAKERY <br /> 0 ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MACHiNESlNo, a1 _ <br /> ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees -ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING <br /> ElHOTEL/MOTEL/No. of Units 11 CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY El 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 /> 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 Disoosal Method _ --� <br /> Animal Waste Disposal Method <br /> Water Supply Source <br /> 6. ❑ CO LTATION FEE ❑ BUSINESS LICENSE <br /> 7. LAN CHECKING FEES T f eti.S / C3 DANCE PERMIT <br /> a. 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 hay 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 Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUA LY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I A Received By January 31 ❑ July 1 3 ReceiveRdEBy July 31 <br /> BASE EXPLANATION BILLING REMITTANCE' s AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE —PJA?�.J GiC_ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> --�f- -- ----- — Issuance Dale Mailed Delivered Pei edby Date Receipt Na Perm[No.PLICANT—RETURMALL-C ALES TO: ENV ENTAL HEALTH PERMITISERVtCES IWI E.HAIEL6AVE"P.O.lies 20P! aTOCKTON.CA iS201 <br />