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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR Make -- <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Lic. No. <br /> --- <br /> BROKER AND/OR <br /> LICENSE AND/OR F000 ESTABLISHMENTS,HOUSING Regist. NO. — <br /> REGISTRATION PUBLIC POOLS.WATER SAMPLING <br /> NUMBER REAL ESTATE INSPECTIONS Color — <br /> POULTRY RANCHES AND KENNELS <br /> Q� MISCELLANEOUS SERVICES /fid <br /> [Application Data 6 "+� B sin /Name To ppear On Pe it ,v2?A/1 �� �/� ��7� 7 <br /> w Type Permit/Service Re ue ted: !�����"/J �" �OlfLrec ApplicantName Address 1C! d - <br /> � _Busines Telephone No. Emerg cy Telephone No. — <br /> Property Location/Address 1� h� r, — <br /> iPropenyOwner �// u G tiy Address ,- <br /> L Operator's Name 1,raJ Address �� � aQ <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/MOTEUNo. 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 COnOninn Canna <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method PUMPS. ELECP 7AL <br /> Water Supply Source Animal We! — <br /> S. Cff CONSULTATION FEE r ❑ BUSINESS <br /> 7. ❑ PLAN CHECKING FEE 7;�w ❑ DANCE PEI <br /> S. REAL ESTATE CRLSZER ELECTRIC <br /> REQUEST: Water Well Inspection 13 Sample❑ Title Company <br /> Sewage System Inspection ❑ Address p/eare 3683139 Gla+ Selo ce <br /> Escrow No. <br /> Seller Seller Address RICHARD R. PRESZLER 19626 HILDEBRAND I.N. <br /> Telephone No. Seller Agent Name CONTRACTORS WC.277947 ACAMPO, CA. 95220 <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 X _._ _ _-- Title _ _ _ Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 A Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE' $ AMOUNT DUE CHECKED <br /> �7 <br /> DATE DATE REMITTED AMOUNT <br /> FEE 3S'� 3S• <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 'a <br /> OTHER <br /> sem_ <br /> � -ti -mss s3 <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered I <br /> APPLICANT—RETONNJ111.COPJESTO: ENVUIONMENTAL HEALTH PERMIT/SERVICES 11601 E.HAZELTON AVE.,P.O.Be[2006 STOCKTON,DA 95201 W <br />