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I. <br /> r ~ Applications Will Ba'prooessed When Submitted Properly Completed. Be re At 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. No. — ---- <br /> BROKER AND/OR FOOD ESTARUSBMENTS,HOUSING <br /> LICENSE AND/OR RegiSt. No. - -- <br /> / PUBLIC POOLS,WATER SAMPLING <br /> REGISTRATION _ <br /> HEAL ESTATE INSPECTIONS Color <br /> NUMBER POULTRY RANCHES AND KENNELS !� I- l <br /> e_1 MtSCELLANEOUSSERYICES ` �t <br /> r� l 1 .1 ) <br /> [Application Date Ll J Busine s/Name To Appear On Permit - — <br /> 4,Type Permit/Service Reque ted: ' <br /> =Applicant Name Ad ress� X7 `7 <br /> _._ Busl ss Telephone N yt Emergency Telephone No. 4' - <br /> Properly Location/Address ~s nrlU e, <br /> -KL <br /> Property Owner'-I -z — Address7�L <br /> l Operator's Name - .t Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Seating Capacity <br /> 1:1RESTAURANT 1:1FOOD MARKET RETAIL 13FOOD MARKET WHOLESALE 11 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/MOT€L/No. of Units C1 CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces <br /> 3. WATER QUALITY 11 WATER SAMPLE (Bacterial) 11 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 /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds <br /> ❑ KENNEL/Runways /Animal Population No. f No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Wtar Supply Source Animal Waste Disposal Method <br /> 8.X CONSULTATION FEE BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> a. 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 /> 6 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 lags p^ ules ander ��� °*e San Joaquin Local Health D' riot. <br /> ��� - -gs <br /> r Till <br /> Date <br /> APPLICANT'S SIGNATURE "\. <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Januar/1&Received By January 31 ® July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> s.vO <br /> FEE <br /> LESS <br /> PRORATION -- <br /> PLUS <br /> PENALTY <br /> OTHER <br /> a <br /> r <br /> OTHER <br /> .qr/� v <br /> 0 <br /> Received by Date iQt No. Permit No. Issuance Mailed Delivered = <br /> APPLICANT—RETXWXALLCOaLES.TO. ENV NTAL HEALTH PERMIT/SERYtCES 1601 E.HAZEL E.,P.O.Boz 14W STOCKTQN.CA 9#261 <br /> W <br />