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Applications Will Be Prow,•-essed When Submitted Properly Completed. Be SureTro Sign The Application. <br /> ENGINEER'S AND/OR SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> APPLICANT'S AND/OR <br /> CONTRACTOR AND/oil - APPLICATION GENERAL <br /> BROKER AND/OR ENVIRONMENTAL IF VEHICLE INVOLVED, <br /> LICENSE AND/OR HEALTH PERMIT/SERVICES Make GIVE <br /> REGISTRATION F000 ESTABLISHMEll HOUSING <br /> NUMBER PUBLIC POOLS, WATER SAMPLING Lic. No <br /> REAL ESTATE INSPECTIONS Regist. No. <br /> POULTRY RANCHES AND KENNELS Color_ <br /> rADPIICefi n Daie -��- MISCELLANEOUS SERVICES <br /> Business/Name To A ----- <br /> vTY Permit/ rvice Requested: PPear On Permit GCS C. <br /> =ApplicantnN'ame G4' 2Mc7ct7leat� �—�w(w�e�cSg, (71 Sf lL <br /> g g5 Z yUI 6S <br /> L-- "' ddress <br /> Property Location/Atltlress -- Business Telephone No.__ _ � �s`/ �hA T� QS C{y9 k <br /> 1Pro ert ��le-L.� TF2 -----<-s— Emergency Telephone '— - <br /> P Y Owner(,, =� 9 Y No. <br /> L Operator's Name C �.lc jj - Address <br /> Aodr <br /> 1. FOOD ESTABLISHMENTS �f e;A --- <br /> __ Address t u� <br /> ❑ RESTAURANT Total Building Sq. Footage s--r- og»q <br /> ❑ FOOD PROCESSING OgryTOD MARKET RETAIL Restaurant,Maximum Seating Capacity <br /> ❑ FOOD MARKET WHOLESALE <br /> ❑ ROADSIDE FOOD STAND COMMISSARY ❑ ICE PLANT E3 MEAT MARKET <br /> ❑ CONFECTIONARY STORE 11 LIQUOR STORE ❑ BAKERY <br /> ❑ VENDING MACHINES/No.p} FOOD SALVAGER ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ FOOD CROP HARVESTING/No.of Field Employees ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ALL APPLICANTS: Total Employees Including Operators <br /> Z. HOUSING <br /> ❑ HOTEUMOTEL/No. of Units <br /> ❑ MOBILE HOME PARK/No. of Spaces ❑ CERTIFICATE OF OCCUPANCY <br /> 3. WATER QUALITY ❑ WATER SAMPLE(Bacterial <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY CHEMICAL <br /> NO.OF PUBLIC SERVED(Connections) WATER HAULER <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ <br /> 5. VECTOR CONTROL ❑ SPA 13 WADING POOL C3 NATURAL BATHING PLACE <br /> POULTRY FARM/Maximum No. of Birds <br /> ❑ KENNEL/Runwa <br /> YB /Animal Population No. <br /> Sewage Disposal Method ---------- No.Of Confining Cages <br /> Solid Waste Disposal Method ------ <br /> Wate�rlSupply Source <br /> i <br /> 41 <br /> CONSULTATION FEE 3,5-, 0 Animal Waste Disposal Method <br /> `�v+-•�.�pLAN CHECKING FEE ❑ BUSINESS LICENSE <br /> B. REAL ESTATE DANCE PERMIT <br /> REQUEST: Water Well Ingmtlon❑ Sample❑ Title Company <br /> Sewage System Inspection ❑ Address_ <br /> Escrow No. Tele. No. <br /> - <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 and regulations of the San Joaquin Local Health District. <br /> APPLICANTS SIGNATURE u __. _ Title E N6,-� � Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is DUM:LI ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 a Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 1 — - <br /> PESS <br /> RORATION c6 0 00 <br /> PLUS <br /> PENALTY /� T <br /> OTHER <br /> Q <br /> OTMER <br /> ecelved by - ual Rece,pt No Permit No. laauen a Date Mailed Delivered I <br /> APPLICANT-RETUAIX CaPIU TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAIELTON AVE_P.O.Box 2009 STOCKTON,CA 95201 W <br />