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w <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGI AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> PLICANT'S S; 10 <br /> Make <br /> NTRACTOR AND/ ENVIRONMENTAL HEALTH PERMIT/SERVICES -- <br /> BROKER AND/ R Lic. No. <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> REGISTRATIONC '� l` PUBLIC POOLS,WATER SAMPLING Reglst. No. <br /> . <br /> NUMBER �l�7A /J Ltt-WSC 8REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> '1 <br /> MISCELLANEOUS <br /> , SERVICES <br /> rApplication Date � �?bo Business/Name To ApDear On Permit _) C SSL <br /> J� <br /> Type Permit/Service Requested: Tcr..t12- 2.�'moUF�, — aha i IL'Q� <br /> Applicant Name �JL-%��r •^- Zwt cA tea ac'>`� Address 'Xk"F.\ IA-.F11\ \�1t2 <br /> S � � <br /> --Business Telephone No. "/!o cid// Emergency Telephone No. rL�071 gs <br /> Property Location/Address M — d2 <br /> Property Owner 6CiT1L�G NFAA Address �`L`6 L-.�t4 Wy Ycti�- S'j-o c� <br /> L Operator's Name N+1"vVe �( >,{1n.,w� Address �(oC l.Y�l4-P,-Q.I oo tpcL Sil <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 /> ❑ HOTEUMOTEUNo.of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces <br /> 3. WATER QUALITY 13 WATER SAMPLE (Bacterial) 11 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 i <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 /> 6. ❑ 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 a e Ion Mon San Joaquin Local Health District. p/ <br /> APPLICANTS SIGNATURE X z 7� _ Title 1P Data 3 3 O C> <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 18 Received By January 31 ❑ July 1 B Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE <br /> EXPLANATION DATE GATE REMITTED AMOUNTDUE CHECKED <br /> -- AMOUNT <br /> FEE - 00Q <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER /^7r <br /> OTHER <br /> W <br /> Received by <br /> Date Receipt No, Permit No. Issuance Date Mailetl Delivered ° <br /> APPLICANT—RETLaNLLL.1101ESi0: ENYUIONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTOH,CA 95201 <br /> W <br />