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Applications Will Be Processed When Submitted Properly Completed. Be Sure To The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 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 FOOD ESTABLISHMENTS,HOUSING <br /> REGISTRATION PUBLIC POOLS,WATER SAMPLING Regist. No. <br /> NUMBER - REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES l <br /> [Application Date S - Busi ss/NAme To Appear On rmit _ LI �+6-ctP-11-S t7 <br /> Type Perm it/Se rvicj equested: <br /> <Applicant Name % L e - v VL—_ A dress <br /> -- - �_r usl ess Tele hone No._ �` L _. _ Emergency Telephone No. <br /> IL Property Location/Address �� �(� V �SO - <br /> j Property Owner lo\ �L _ Address <br /> I Operator's Name 1 Address -- <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 /> ❑ HOTEL/MOTEL/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 /> 0. MCONSULTAT10N FEE 7 5 t ❑ 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,rid rules anddreggulatidons of the San Joaquin Local Health District. t <br /> APPLICANT'S SIGNATURE X � 1' L'��Yy>L -1 �7N-A{A Title Lc 1 / 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 _AM LINT <br /> FEE � DU <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> v <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered = <br /> APPLICANT—RETI WHALL.CURIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2002 STOCKTON,CA 95201 W <br />