Laserfiche WebLink
i <br /> Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> G A Make <br /> NTRACTOR AND/ ENVIRONMENTAL HEALTH PERMIT/SERVICES -- <br /> BRo Lic. No. <br /> LICENSE AND/OR F000 ESTABLISHMENTS,HOUSING <br /> REGISTRATION PUBLIC POOLS.WATER SAMPLING RegiSt. N0. <br /> NUMBER 4/fo7ag3 REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> / MISCELLANEOUS SERVICES <br /> � f� <br /> rApplication Date T" -'�YL- Business/Name To Appear On Permit /n!C- <br /> !Applicant <br /> Permit/ServiceRequested: 'T.A.JJ{JSIj3�.ryT/cuts __ _ s_L _ <br /> !Applicant Name F-"CIS(An 1'-nn.1c ill' NC_ Address21!91 <br /> __ <br /> ._ Busin'ess'Tele/phone No. �- YCc3-�!/ Emergency Telephone No..70�- <br /> Property Location/Address I ORL/ 149 <br /> i Property Owner I/n f ORAS,i� Ai-P rtka_ Address /f1F/ (-1- M-4. o(" <br /> L Operator's Name Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Seating Capacity <br /> CI 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 /> S. 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 /> S. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. RI PLAN CHECKING FEE Ngrin U4T(AC!5PA lA ❑ DANCE PERMIT <br /> S. 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 I 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. ll —Ofd <br /> APPLICANTS SIGNATURE X -VA.A g 444 �l Title <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE' S <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 6k;P T GO <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> `1-7 -Rt lisp <br /> 0 <br /> Received by Oele Receipt Na. Permit No. Issuance Date Mailed Delivered Z <br /> APPLICANT—RETUaNJ COBIESTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 111011 E.HAZELTON AVE.,P.O.Bea Mile STOCKTON,CA 25201 W <br />