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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ENGINEER'S AND/OR GENERAL <br /> ACONTRACTOR PPLICANT'S AND/OR APPLICATION IF VEHICLE INVOLVED, GIVE <br /> BROKER ANDVOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> BROKER AND/OR Make <br /> LICENSE AND/ORFOOD ESTABLISHMENTS,HOUSING LIC. No. <br /> NUMBER <br /> REGISTRATIONPUBLIC POOLS.WATER SAMPLING <br /> NUMBER REAL ESTATE INSPECTIONS ReglSf. NO. _ <br /> POULTRY RANCHES AND KENNELS Color _ <br /> rApplication Date MISCELLANEOUS SERVICES / <br /> I Business/Name To App ar On Per t Va L /S��p.S-S 6 <br /> wType Permit/Service Req eted _ C���• D 12 <br /> P�Ap I cant Nama_ O ��T/ S' i,Li L i �Adtlress —._�•��DN ��_� , Business Telephone No ///// (�operty Location/Address -77; ,�—� Emergency Telephone No. <br /> 1 Property Owner <br /> L Operator's Name — Address <br /> 1. FOOD ESTABLISHMENTSAddress ,S�Cj-/yip <br /> 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 <br /> 13ROADSIDE FOOD STAND 11LIQUOR STORE ❑ BAR 13 BAKERY <br /> 13 CONFECTIONARY STORE 13 FOOD SALVAGER 11 ❑ ITINERANT RESTAURANT <br /> FOOD DEMONSTRATION 11 FOOD VENDOR <br /> 13 VENDING MACHINES/No. of <br /> 1) FOOD CROP HARVESTING/NO.of Field Employees ❑ MOBILE FOOD PREP. UNIT 11 VENDING VEHICLE <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units <br /> 13 ❑ CERTIFICATE OF OCCUPANCY <br /> MOBILE HOME PARK/No.of Spaces <br /> 3. WATER QUALITY 13WATER 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. <br /> Sewage Disposal Method No.of Confining Cages <br /> Solid Waste Disposal Method <br /> Water Supply Source <br /> S. OCONSULTATION FEE Animal Waste Disposal Method <br /> 7. ❑ PLAN CHECKING FEE ❑ BUSINESS LICENSE <br /> S. REAL ESTATE ❑ DANCE PERMIT <br /> REQUEST: Water Well Inspection 13 Sample❑ Title Company <br /> Sewage System Inspection ❑ Address_ <br /> Escrow No. Tele. 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 ru s and regulations of IV San Joaquin Local Health District. <br /> APPLICANTS SIGNATURE X <br /> __ Title s•��a�/ Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE <br /> ❑ EACH 11 January 1 A Received By January 31 ❑ JulY 18 Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNTDUE CHECKED <br /> FEE ! AMOUNT <br /> LESS D <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Data Receipt No. Permit No. c <br /> APPLICANT— Issuance Oate MaileE Delivered <br /> FIETURNJLL.CORIE ii ENYIaONMENTAL HEALTH PERMIT/SERVICES 1Q01 E.HAZELTON AVE.,P.O.Bos 2002 ATOCKTON,CA 95201 <br /> W <br />