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Applications Will Be Processed When Submitted Properly Completed. Be Sure o Sign The Application. <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR Make. - --- - - <br /> "ONT_ T ND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES LicNo. - - — <br /> BROKER AND/OR <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,HOUSING Reg ist. No. <br /> REGISTRATION <br /> G,! PUBLIC POOLS,WATER SAMPLING --_ -- <br /> Fr`7 <br /> NUMBER _ REAL ESTATE INSPECTIONS Color— <br /> POULTRTRANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES ,,/� A C�ro-,� r <br /> rA Application Date �/ Business/Name TcLAppear On Per 1t V -S y — _---- <br /> P P �f -- N�G �wr r� ? JT- C_ .. i.Glf <br /> FType Permit/Servic Requested: �� _--� <br /> UApplicant Name Jc Address '}Z <br /> �✓1 _ Business Telephone No. �ly ��5 Emergency Telephone No. <br /> Property Locationf[iAddres Vwq/p) WG --- <br /> J Property Owner U�� rl'rt OI&V-S 5�-' V40t- SS Address - Q'OX ICX> <br /> I Operator's Name 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 /> B. CONSULTATION FE ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 SampleC 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 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, and..r les and�,gulations oryi S Joaquin Local Health District. <br /> y� C%tCyC�7CC_3 / iy�?[" <br /> APPLICANT'S SIGNATURE -- <br /> Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ JuVy 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $$ AMOUNT DUE CHECKED <br /> ^� DATE DATE REMI,Tr`pTED AMOUNT <br /> FEE �LJ lam' <br /> LESS <br /> PRORATIONPLUS <br /> PENALTY <br /> OTHER <br /> d <br /> m <br /> OTHER <br /> _ r <br /> 0 <br /> Received by Dale Receipt No. Permit No. Issuance Date Mailed Delivered r <br /> APPLICANT—RETLMU AIICORLESTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bon 2000 STOCKTON,CA 25201 W <br />