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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign 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 <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,MOUSING LIC. No. <br /> REGISTRATION PUBLIC POOLS.WATER SAMPLING Reglst. No.--- <br /> NUMBER REAL ESTATE INSPECTIONS Color <br /> --- <br /> POULTRY RANCHES AND KENNELS -- <br /> MISCELLANEOUS SERVICES <br /> Application Date Business/Name To A <br /> ' ppear Permi <br /> rType Permit/Service Requested: �" 'I/V <br /> Applican �o� LO�i SP UfCtP A o Address YGE AJ 00h <br /> Business Telephone No.--� /1 /a 2'7 Emergency Telephone No. — <br /> Property Location/Address WQy "�0 <br /> Property Owner Address �pE-�7 /r iYH IIJ/ <br /> L Operator's Name A /r 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 ❑ LIOUOR 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 /> e. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds <br /> ❑ KENNEL/Runweys /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source 122 Animal Waste Disposal Method <br /> S. CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> S. 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 Serf Joaquin Local h District. <br /> / a - O <br /> APPLICANT'S SIGNATURE Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 S Received By July 31 <br /> BILLING REMITTANCE' S REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> GATE DATE REMITTED <br /> `` AMOUNT <br /> FEETa <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> .Z/10 /r—to �1f k° <br /> Received by to Receipt No. Permit Na. laauance Data Meiled Delivered t <br /> APPLICANT—RET�CAMMTO. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1a01 E.HAZELTON AVE..P.O.Be.2009 STOCKTON.CA OS201 M <br />