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Applications Will Be Proc�essed When Submitted Pro <br /> Ompleted. Be Sure To <br /> SAN JOAOUIN LOCALEty C <br /> HEALTH DISTRICT The Application. <br /> ENGINEER'S AND/OR <br /> APPLICANT'S AND/OR GENERAL <br /> CONTRACTOR AND/OR APPLICATION <br /> HEALTH P IF VEHICLE INVOLVED, GIVE <br /> BROKER AND/OR ENVIRONMENTAL <br /> LICENSE AND/OA PERMIT/SERVICES Make <br /> REGISTRATION FOOD ESTABLISHMENTS,HOUSING <br /> NUMBER PUBLIC POOL LIC. No. <br /> -- REAL ESTATE INSPECTIONS SAMPLING --- <br /> p Regist. No. <br /> rApplication Data 3�� O✓G POULTRY RANCHES AND KENNELS Color <br /> MISCELLAMEOUS SERVICES <br /> a Type Permit/Service Re ues d; Bud' ess/Name -o A Pear On Pe it <br /> Applicant Name <br /> O< — <br /> Address <br /> (Property Location/Address 7 3 — Business Telephone No. Z 41 <br /> •-CZ <br /> i Property Owner �lG/n Z , Emergency Telephone No. <br /> L Operator's Name Address .l�1tf <br /> T. FOOD ESTABLISHMEN78 4u <br /> Total Building Sq. Foote a Address <br /> ❑ RESTAURANT g <br /> ❑ FOOD MARKET RETAIL ❑ Restaurant,Maximum Seating Capacity <br /> ❑ FOOD PROCESSING PLANT [3 COMMISSARY <br /> MARKET WHOLESALE ❑ <br /> ❑ ROADSIDE FOOD STAND ❑ COMMISSARY ❑ ICE PLANT MEAT MARKET <br /> ❑ CONFECLIQUOR STORE El ❑ BAKERY <br /> TIONARY STORE 11 <br /> ❑ VENDING MACHINES/No. of FOOD SALVAGER ❑ FOOD DEMONSTRATION O ITINERANT RESTAURANT <br /> ❑ FOOD CROP HARVESTING/No,of Field E ❑ MOBILE FOOD PREP. UNIT ❑ FOOD VENDOR <br /> ALL APPLICANTS: Total Employees Including Operators VENDING VEHICLE <br /> Z. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units <br /> ❑ MOBILE HOME PARK/No. of Spaces ❑ CERTIFICATE OF OCCUPANCY <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ <br /> NO. OF PUBLIC SERVED(Connections) WATER HAULER <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of BirdsADING POOL E3 NATURAL BATHING PLACE <br /> ❑ KENNEL/Runway. /Animal Population No. <br /> Sewage Disposal Method No.of Confining Cage. <br /> Solid Waste Disposal Method <br /> Water Supply Source <br /> 8. CONSULTATION FEE_��G ( Animal Waste Disposal Method <br /> 7. ❑ PLAN CHECKING FEE ��� ❑ BUSINESS LICENSE <br /> 8. REAL ESTATE ❑ DANCE PERMIT <br /> REQUEST: Water Well Inspection El Sample❑ <br /> Sewage System Inspection ❑ Title Company <br /> Address <br /> Escrow No. _ <br /> Tele. 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. andrules and regulations of the San Joaquin Local Health District. <br /> APPLICANTS SIGNATURE X -� Title cl fll FSM1¢AI <br /> Date <br /> FOR DEPARTMENT USE ONLY <br /> F.+i�o....-O a,wviweer OrfR UNIT ❑ PER SITE C1 EACH <br /> ❑ January 1 a Received By January 31 ❑ July 1 S Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE <br /> DATE $ REMIT <br /> FEE DATE REMITTED AMOUNT DUE CHECKED <br /> O U <br /> AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by we Receipt No. <br /> APPLICANT—RETURNJUL Permit No. lasuence Dete <br /> COBIESTO: ENYIRONMENTAL HEALTH PERMITMERVICES Mailed Delivered o <br /> INN E.HAZELTON AVE.,P.O.Roe' a STOCKTON.CA MMR <br /> W <br />