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Applications Will Be Processed When Submitted Properly Completed. Be Sure 1 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/ORMake — --- — - <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Lic. Na.- - - - -- <br /> BROKER ANWOR FOOD ESTABLISHMENTS,HOUSING <br /> LICENSE AND/OR Regist. No -_ -- <br /> REGISTRATION REAL ESTATE <br /> ESTTATATES.WATER SAMPLING <br /> RE INSPECTiONs Color--- -- <br /> NUMBER _ - POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> [Application Date `; Business/Name To <br /> c Appear On Permit <br /> _ <br /> .Type Permit/Service Requested: vk- <br /> iApplicantName Address <br /> f { Telephone No. <br /> IL <br /> Business Telephone No. ` --' � Emergency - <br /> ILProperty Location/Address `�+'�`� ) >`� - �� i r✓-I :J �- -- - - - - <br /> �Property Owner Address _ -- - - - - - <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. <br /> _2. HOUSING <br /> 11HOTEL/MOTEL/No. of Units - ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces - <br /> 3. WATER QUALITY 13 WATER SAMPLE (Bacterial) 13 CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections} <br /> q. 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 T _ Animal Waste Disposal Method <br /> B. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE - - <br /> 7. ❑ PLAN CHECKING FEE - _ ❑ DANCE PERMIT <br /> B. 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 1 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 San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X _ Title Date T <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 AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> _ --- _ <br /> PENALTY --- -- <br /> OTHER a <br /> OTHER - - <br /> a <br /> Received by Date Receipt No Permit No Issuance Date Mailed Delivered 2 <br /> APPLICANT—RETLRNALLGOPLFS TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Roy 2009 STOCKTON.CA 95201 <br /> W <br />