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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 /> APPLICANTS AND/OR Make -- <br /> CONTRACTORAND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> BROKER AND/OR Lid.No. <br /> LICENSE AND/OR FOOD ESTABUSHMENTS.NOUSING Regist. No- <br /> REGISTRATION PUBLIC POOL&M►TEN SAMPLING <br /> NUMBER REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> 'Application Data .G Business/Name To Appear On Permit <br /> !Property <br /> Type Permit/Se Nice Requested: YcApplicant Name / AddressBusiness Telephone No. '% �� ���r4 Emerrgency Telephone No.Location/Address \` , 1 ^ \. (' <br /> Property Owner /. 1621/? Address79,'4-,,. - <br /> L Operators Name .5.,. - Address S,. (- <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 /> 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 /> _ <br /> Water Supply Source Animal Waste Disposal Method <br /> IL ZCONSULTATION FEE (➢Cast IIZOMOV& ❑ BUSINESS LICENSE <br /> T. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> L 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. Seiler 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,anwales and re ulations of th San Joaquin Local Health District. <br /> i <br /> APPLICANTS SIGNATURE X iLITitle L5764 1,,r Date <br /> FOR FITMENT USE ONLY <br /> FN Is DOC ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 A Received By July 31 <br /> BILLING REMITTANCE S REMIT I <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS .I[� <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER D <br /> IV f7 (�—> tri V 4y o <br /> Received by Date Receipt Na. Permd No. Issuance Data Mailed DMvered x <br /> APPLICAIrT—RETIIaK♦r r CCPJEa TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 11101 E HAZELTON AVL P.O.Dos Ref STOCKTON•CA eaZol <br />