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ApRIicllllpna WIII ArMessed When Submitted Properly Completed. 8e10.To Sign The Application. <br /> SAN JOAQUIN LOCAL Pp tt <br /> ENGINEER'S AND/OR WEALTH DISTRICT <br /> APPLICANT'S AND/OR <br /> CONTRACTOR AND/OR APPLICATION GENERAL <br /> BROKER AND/OR <br /> LIG A ENVIRONMENTAL HEALTH PEO IF VEHICLE INVOLVED,GIVE <br /> REGISTRSTRATION ON PERMIT/SERVICES Make <br /> NUMBER FOOO ESTABLISHMENTS,HOUSING --- <br /> PUBLIC POOLS,WATER SAMPLING i c. No _ <br /> REAL ESTATE INSPECTIONS Regist. No. <br /> POULTRY RANCHES ANO KERNELS Color <br /> Application Date MISCELLANEOUS SERYICES - --- --__-__-_- <br /> is TYPe PermitfService Requested: Business/Name To Appear On Permit <br /> uApplicant Name ��-- - - --- - ----- - ----- - --- _ <br /> � Address <br /> (Property Location/Address ----- Business Telephone No. - <br /> iProperty Owner_ - ----- Emergency Telephone No. <br /> I Operator's Name �� �--:- Address -- - -- ---- -- --- <br /> 1. FOOD ESTABLISHMENTS ----- ---- --- -- <br /> Total BuildingAddress _ __ <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL Sq. Footage Restaurant, Maximum Seating Capacity --t --- -- <br /> ❑ FOOD PROCESSING PLANT ❑ 0 FOOD MARKET WHOLESALE ❑ - - --- - — <br /> ❑ ROADSIDE FOOD STAND ❑ COMMISSARY ❑ ICE PLANT MEAT MARKET <br /> ❑ CONFECTIONARY STORE ❑ LIQUOR STORE BAR ❑ BAKERY <br /> ❑ VENDING MACHINES/No. of FOOD SALVAGER ❑ ITINERANT RESTAURANT <br /> ❑ i=00D DEMONSTRATION <br /> ❑ <br /> FOOD CROP HARVESTING/ MOBILE FOOD PREP. UNIT ❑ FOOD VENDOR <br /> No. of Field Employees EJ VENDING VEHICLE <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No,of Units _ <br /> ❑ MOBILE HOME PARK/No. of Space <br /> ❑ CERTIFICATE OF OCCUPANCY <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY❑ CHEMICAL <br /> NO. OF PUBLIC SERVED fConnections) ❑ WATER HAULER <br /> 4• RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ <br /> 5- VECTOR CONTROL ❑ POULTRY FARM/Maximum No. WADING POOL El NATURAL BATHING PLACE <br /> 0 KENNEL/Runways of Birds <br /> �. /Animal Papulation No <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method ���` Na.of Confining Cages _ <br /> Water Supply Source <br /> 8• CONSULTATION FEE- Animal Waste Disposal Method <br /> 7. ❑ PLAN CHECKING FEE <br /> ❑ BUSINESS LICENSE <br /> 8. REAL ESTATE DANCE PERMIT <br /> REQUEST: Water Weil Inspection❑ Sample❑ 1 <br /> Sewage System Inspection ❑ Title Company <br /> Escrow No. Address <br /> Seller <br /> Tele. No, <br /> Telephone Na, Seller Address <br /> _ 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 " <br /> ordinances, state laws,and rules and regulations of the San Joaquin Local Health District. <br /> X q County <br /> 4 F'FL l4HA(r 5 sfGNATURE /� <br /> Title <br /> Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due; 11 ANNUALLY <br /> ❑ PER UNIT PER SITE <br /> ❑ EACH ❑ January1& <br /> BASE Received By January 31 ❑ Jul 9 & <br /> EXPLANATION BILLING REMITTANCE' y Received-M July 31 <br /> GATE DATE S REMIT <br /> PEE REMITTED AMOUNT DUE CHECKED <br /> LESS , <br /> AMOUNT <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER -- <br /> OTHER <br /> I -- <br /> Receivetl by r <br /> Date Receipt No. <br /> APPLICANT—RETURNJL�L, Permit No, — <br /> CdRlESTO: ENVIRONMENTAL HEALTH PE Issuance Date Marled a <br /> RMIT/SERVICES Delivered <br /> 7807 00 <br /> E.HAZELTON AVE.,P.O.Bo=200 <br /> STOCKTON,CA DS201 w <br />