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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL ENGINEER'SAND/OR APPLICATION IF VEHICLE INVOLVED, GIVE A APPLICANT'S HT'SAND/OR CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make BROKER AND/OR BASE Lic. No LICENSE AND/OR FOOD ESTABLISHMENTS, HOUSING --- REGISTRATION PUBLIC POOLS. WATER SAMPLING Regist. No. NUMBER REAL ESTATE INSPECTIONS Color POULTRY RANCHES AND KENNELS FEE r%/� ,%- MISCELLANEOUS SERVICES rApplication Date - Business/Name To Appear On Permit Type Permit/Service Requested:i i Applicant Name Address CL _ r� °`'= ' ". p Emergency Telephone No. CL Business Telephone No Property Location/Address Property Owner Address t Operator's Name Address 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE ❑ FOOD CROP HARVESTING/No. of Field Employees ALL APPLICANTS: Total Employees Including Operators 2. HOUSING ❑ HOTEUMOTEUNo. of Units ❑ CERTIFICATE OF OCCUPANCY ❑ MOBILE HOME PARK/No. of Spaces 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER NO, OF PUBLIC SERVED (Connections) 4. RECREATIONAL HEALTH 11 SWIMMING POOL 11 SPA ❑ WADING POOL C1 NATURAL BATHING PLACE S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds ❑ KENNEL/Runways /Animal Population No. _ No. of Confining Cages Sewage Disposal Method Solid Waste Disoosal Method Water Supply Source Animal Waste Disposal Method 6. ❑ CONSULTATION FEE%C ❑ BUSINESS LICENSE 7. ❑ PLAN CHECKING FEE DANCE PERMIT S. REAL ESTATE REQUEST: Water Well Inspection Sample❑ Title Company Sewage System Inspection ❑ Address _ Tele. No. Escrow No. Seller Seiler Address Telephone No. Seller Agent Name Service Request For Date I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. APPLICANT'S SIGNATURE X "' Title Date FOR DEPARTMENT USE ONLY Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SI rE ❑ EACH ❑ January 1 & Received By January 31 ❑ July 1 & Received By July 31 REMIT BASE BILLING EXPLANATION REMITTANCE' S AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER I Received by Date R-ceipt No. Permit No Issuance Date Mailed Delivered •oe, ,r•ur-eefneu •, , rnn�ea fn. eum rur •, ..r.. �.. neeutr,r re..,. -rte ..... r ... ��. ,,.� .... �__ ,,.� .�...-..�.... ..........