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Applications Will B eased When Submitted Properly Completed. B re To Sign The Application. <br /> ASJOAQUIN LOCAL HEALTH DT GENERAL <br /> ENGINEER'S AND/OR <br /> APPLICANT'S AND/OR APPLICATION IF VEHICLE INVOLVED. GIVE <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make— __ <br /> BROKER AND/OR Lic. No. _ <br /> LICENSE AND/OR F000 ESTABLISHMENTS,HOUSING - - -- <br /> REGISTRATION PUBLIC POOLS.WATER SAMPLING Regist. No._ _ <br /> NUMBER _ REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS _ <br /> MISCELLANEOUS SERVICES <br /> rApplication Date J 6 usi ss/Name T Appear S Permit t �JJ.•�yC,G, /�Erl�,+kT.4 \V_r'G <br /> Type Permit/Service Requested: <br /> lt <br /> Applicant Name Add MCLISID <br /> _Busi ass Telephone No. Emergency 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 /> d 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 /> ❑ HOTEUMOTEUNo. 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 /> ❑ KENNEL/Runways /Animal Population No. _ No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> W er upply Source Animal Waste Disposal Method <br /> G. 8CONSULTATION FEE BUSINESS LICENSE <br /> 7. K PLAN CHECKING FEE ❑ DANCE PERMIT <br /> S. REAL ESTATE <br /> REQUEST: Water Wall 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 x Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee U Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July i A Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE' REMIT <br /> S AMOUNT DUE CHECKED <br /> d DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY g <br /> OTHER <br /> OTHER <br /> Recei by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> AP LICANT—RETWINJLI.00BIE&TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa floe STOCKTON,CA 95201 <br />