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Applications Will Be .asod When Submitted Properly Completed. Be Sure Io Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE -- <br /> APPLICANTS AND/ORMake <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Lic.No. — — <br /> BROKER AND/OR FOOD ESTABLISHMENTS.HOUSING <br /> RegISI.No. <br /> LICENSE AND/OR _— — -- <br /> REAL <br /> POOLS WATER SAMPLING <br /> REGISTRATION <br /> REAL ESTATE INSPECTIONS Color <br /> NUMBER POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> Application Dale ` Business/Name To Appear On Permit <br /> O 6✓l0 mit✓�� Pg�rd��L �'✓�S <br /> "Type Permit/Service Requested:��� � <br /> Applicant Name— Lar 'fes �B'J� Address <br /> 1_3 _ <br /> Business Telephone No. Emergen 6 q eph ne No. <br /> _ CO �'�C <br /> Property Location/Address <br /> i Property Owner �e� 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 /> Z. HOUSING ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ HOTEL/MOTEL/No.of Units <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 /> a. 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 /> S. ❑ CONSULTATION FEE — ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> S. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 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 rules and regulations of the an Joaquin L I Health District. o /� <br /> APPLICANTS SIGNATURE X <br /> DEPA NT US ONLY <br /> FM Is DUI: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ ACM ❑ January 1 8 Received By January 31 ❑ July 1 8 RecoivREMIITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE f AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 9Q k <br /> 360 °' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �/1H Yrb � F tSb o S <br /> Received by Dete Receipt No. Permit No. Issuance Date Mailed Delivere0 } <br /> APPLICANT—RETOYNALL,CORIESTO: ENVUIDNMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Noe 1 ST�YOCC`rKKTT�ON.CA IMM <br /> W <br /> Xy 0006� �'l..'yv`ClY • A v� <br />