Laserfiche WebLink
Applications Will Be PlIssed When Submitted Properly Completed. Be Surte (ign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/ORMake -- <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Lic. No. -- <br /> BROKER AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> LICENSE AND/OR PUBLIC POOLS.WATER SAMPLING Regist. NO. — <br /> REGISTRATION REAL ESTATE INSPECTIONS Color <br /> NUMBER - POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> FApplication Date _ Business/Name To Appear On Permit — <br /> ,eType Per nit/Servics Requested: <br /> Applicant Name _ Address <br /> L _Business Telephone No. Emergency Telephone No. <br /> (Property Location/Addres S I <br /> Property Owner cr z Address �! ✓r�Lw <br /> L Operator's Name Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Sealing 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 /> 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 /> ❑ KENNEURunwaya /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 /> B. ❑ CONSULTATION FEE — ❑ BUSINESS LICENSE — <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT - <br /> 8. 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 X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS DMO: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 a Receiv REM July 31 <br /> BASE EXPLANATION BILLING REMITTANCE E AMOUNTDUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEELESS ` <br /> 3p•vo �rm <br /> PRORATION y• O-''O'`` ' <br /> PLUS C� �w Hbw (ylfq. " <br /> PENALTY r <br /> OTHER S(�•QD �'F+H S {'I( t /� � m <br /> OTHER 1 JDiDD /' 76- 6 'n <br /> C4Ilk- — bid �aclue- Ga, 00 X <br /> Received by Dete Receipt No. Pemnt No. <br /> —1....C.Date Mailed Deli red i <br /> W <br /> APPLICANT—RETLLRUALLCONALTO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE.,P.O.Box fOW STOCKTON,CA swot <br />