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Applications WIII Be Pied When Submitted Properly Completed. Be Su,*Ign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/ORAI�PLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make .___ <br /> BROKER AND/OR Lib. No. <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,HOUSING Regist. No <br /> PUBLIC POOLS,WATER SAMPLING g <br /> NUMBER _ REAL ESTATE INSPECTIONS Calor <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS <br /> [Application Date Business/NameTo Appear On Permit <br /> E <br /> Type Permit/Service Requested: <br /> Applicant Name _ Address �. <br /> U <br /> u _ Business Telephone No. _ Emergency Telephone No. <br /> (Property Location/Add r ss <br /> I Property Owner 7 Address <br /> I Operator's Name Address <br /> t. 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 /> ❑ 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 /> 5. 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 /> Water Supply Source Animal Waste Disposal Method <br /> S. ❑ 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 -P <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 W1-t be done in accordance with San Joaquin County <br /> ordinances,state laws,and rules and regulations of the San Joaquin Loc*l 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 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING EMITTANCE' $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE i5b Q.,L- 2LESS <br /> 'T!L-"1 l�--✓`� 1d'L U <br /> PRORATION eA. .2 5c,t,r k'q re c- i <br /> PLUS <br /> PENALTY fJ ' "U GL C-C, e— 0l� <br /> OTHER --- <br /> Y <br /> OTHER Z . (,0 <br /> Jeri i <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered s <br /> APPLICANT—RETLMMAJ LCsQLE-S TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2004 STOCKTON,CA 95201 W <br /> 96 0 <br />