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} 'y Applications Will 10roc When Submitted Properly Completed. BeSQre To Sig n The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEERS AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/ORMake -- <br /> CONTRACTOR AND/OF1 ENVIRONMENTAL HEALTH PERMIT/SERVICES Lic. No. — <br /> BROKER AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> LICENSE AND/OR PUBLIC POOLS,WATER SAMPLING RegISI. NO. — <br /> REGISTRATION REAL ESTATE INSPECTIONS Color - <br /> NUMBER /J //7 J/L• POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES n <br /> rApplication DateBusiness/Nam T Appear n Permit I—e- �— ----_ <br /> *Type Permit/Service Requl1.a �ed1, 'y 7 <br /> Ap Ilcant Name�`���rc, - Ad ess _� D <br /> _Busi ess Telepho e o 65 —DAIp Emergency Telephone No. b"7r�— <br /> Property Location/Ad r s 6 of - <br /> iProperty Owner Add0-4 ress _ _—d <br /> L Operator's Name Address y <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,MaximWn 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 /> Z. 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 /> ❑ KENNEVRunways /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Weer Supply Source Animal Waste Disposal Method <br /> 8. CCONSULTATION FE f ❑ BUSINESS LICENSE <br /> T. ❑ PLAN CHECKING FEE _ ❑ DANCE PERMIT <br /> S. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 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 ru � and g atio a of the in Local Health Distr' <br /> APPLICANT'S SIGNATURE x / in <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Doe: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 S Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE '1 REMITTED AMOUNT <br /> FEELESS <br /> O O� <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> Let <br /> OTHER <br /> W v <br /> OTHER - <br /> L All �5 � <br /> Received ey Datet No. Permit No. Issue Mailed Delivered <br /> JLi <br /> APPLICANT-IIETURNI.CORIESTO: ENY NTAL HEALTH PERMIT/SERVICES 1001 E.NAZ E.,P.O.Box 100E STOCKTON,CASSMI W <br />