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ENGINEER'S AND/OR <br />APPLICANT'S AND/OR <br />CONTRACTOR AND/OR <br />BROKER AND/OR <br />LICENSE AND/OR <br />REGISTRATION <br />NUMBER _. <br />Applications Will Be *eased When Submitted Properly Completed. Be S. rYo Sign The Application. <br />FApplication Date /- tI <br />aType Permit/Service R <br />iApplicant Name z�%D <br />SAN JOAOUIN LOCAL HEALTH DISTRICT GENERAL <br />APPLICATION IF VEHICLE INVOLVED, GIVE <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br />Lic. No. <br />FOOD ESTABLISHMENTS, HOUSING <br />PUBLIC POOLS, WATER SAMPLING Regist. No. <br />REAL ESTATE INSPECTIONS Color <br />POULTRY RANCHES AND KENNELS,. <br />- <br />MISCELLANEOUS SERVICES { <br />usiness/Name To ppear IT Permit <br />0��-^L-�Ad�dr 55 3 A-. <br />// <br />Business Telephone No.�So 3 VEmergency Telephone No. —� <br />� Property Location/Address <br />iProperty Owner 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 <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 />S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br />❑ KENNEURunways /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 FEET -d&& e1n0✓Q. ❑ BUSINESS LICENSE <br />7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br />S. 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 rules and regulations of the San Joaquin Local Health District. <br />APPLICANT'S SIGNATURE XXdA ��,��/.S) _Title Date <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY <br />❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 <br />❑ July 1 a Received By July 31 <br />BASE <br />EXPLANATION <br />BILLING <br />REMITTANCE' <br />S <br />AMOUNTDUE <br />REMIT <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEE <br />... <br />a/-' y-� <br />✓J o(J <br />LESS <br />PRORATION <br />PLUS <br />nat� <br />PENALTY <br />OTHER <br />OTHER <br />Received by Dale <br />Receipt No. Permit No. Issuance Date <br />Mailed Delivered <br />