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Applleetlona VIII D4,..,,oeeoeed TYhon Submitted Properly Completed.Do , ,:"ro Slgn Tho Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> DO rl"1SR•O AND= APPLICATION IF VEHICLE INVOLVED.GIVE <br /> � ANDION <br /> RACCTOR ENVIRONMENTAL HEALTH PERMIT/SERVICES MOkO <br /> BROKER AND= Lid.No. <br /> UCENW AND✓ R FOOD ESTASLJSS11tE/I BMW Regist.NO. <br /> REGISTRATION 13uBM POOLS,MATE®SAMP11=1 <br /> NUM3ER CEA,ESTATE ISSPECTIOSS Color <br /> PCULTST 6AtdLm AIM 11113=3 <br /> 12LSCELLA1111 1 <br /> rApplication Date �`� Busi eWkhame o Appear Permi <br /> pType Permit/Servic ues <br /> i <br /> Applicant Name Ad ress <br /> _ Business Telephone No. Emergency Telephone No. <br /> Property Location/Address <br /> �PfOporty OLmr Address <br /> L Operator's Name Address <br /> 1. FOOD 110TADLISHMENTS Total Building Sq. Footage Restaurant.Maximum Soating CapcGty <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/MOTEUWo.of Unita ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces <br /> & WATER QUALITY ❑ WATER SAMPLE(Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> LSC-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 Cogoa <br /> Sewage Disposal Method <br /> Solid Wasto Djapodal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> 0. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> 0. REAL ESTATE <br /> REQUEST: Wator Woll Inapoction❑ 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, on f theSan Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE' X Tit Date �a p <br /> OR DEPARTMENT USE ONLY <br /> Fee Is Duo:.Cl—AwjALLY ❑PER UNIT ❑ PER SITE •-, ❑EACH O reoumv 1 a Received By Jerks"31 a July 1A Rx«„ed By A*31. <br /> REMIT <br /> f <br /> BASE EXPLANATION BILLING REMITTANCE*DATE DATE REMITTED AMOUNT DUE CHECKED <br /> /� AMOUNT <br /> FEE D /® i E/ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 7 <br /> OTHE n <br /> 0 <br /> Refyiwd by Date Receipt No. Permit No. Issuance Date Maihd Delivered <br /> Z <br /> APPUCANT—RETL KALLrrnue TO; ENYIrIONMENTAL WEALTH PERMITISERVICES 1901 E.WAZELTON AVIL.P.O.Dos 200 aTOCKTM CA C3= Y <br />