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Applications WIII Be Processed When Submitted Properly Completed.Be SureWign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S ANO/OR APPLICATION IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR Make <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> BROKER AND/OR Lic. No. ---- ---- <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,HOUSING Regist. No. <br /> REGISTRATION PUBLIC POOLS.WATER SAMPLING <br /> NUMBER REAL ESTATE INSPECTIONS Color-- <br /> POULTRY RANCHES AND KENNELS <br /> ���---���---rrr MISCELLANEOUS SERVICES <br /> rApplication Date (3 Business/Name To Appear On Permit -- <br /> *Type Permit/Service Request d: __— <br /> u Applicant Name L —_ Address �s L I� / �C�� d z <br /> Business Telephone No.�� ZJ�� Emergency Telephone No. —_ <br /> Property Location/Address — —. <br /> i Property OwnerztZ� / Add�re1ss — <br /> L Operator's Nam /�Sd7�ss <br /> 1. FOOD ESTABLISHMENTS To al 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 �!7 <br /> ❑ HOTEL/MOTEL/No.of Units ❑ CERTIFICATE OF OCCUPANCY '%%7� ' <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 /> 6. CONSULTATION FEE .95-,Q0 ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> 6. 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 and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE,X �1, G G c Title r'/ �/l� 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 /> BASE EXPLANATION BILLING REMITTANCE' $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS / <br /> PENALTY <br /> OTHER <br /> v <br /> OTHER <br /> i <br /> � o <br /> 0 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered = <br /> APPLICANT—RETURUALLC MUESTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 w <br />