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Applications Will.Be P0saed When Submitted Properly Completed. Be Sure ro Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR <br /> APPLICANT'S AND/OR APPLICATION IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br /> BROKER AND/OR -- <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,MOUSING Lic. No. <br /> REGISTRATION PUBLIC POOLS,WATER SAMPLING Regist. No <br /> NUMBER REAL ESTATE INSPECTIONS Color_ <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES ' <br /> Application Date / <br /> Business/Name Permit <br /> ) / <br /> To Appear On Peit �� <br /> FType Permit/Service Requested: I (# <br /> Applicant Name I,(��( E�/� 1 <br /> �— '��/�r t/ /� A dress �SLL✓ 1 I�f •iU <br /> __ Btlxess Telephone No. - � _ Em rgency Telephone No.11 L 713 <br /> Property Location/ d res, C �r j ^ ( I) <br /> MI <br /> Owner �� 1 Address 7A,112LA 41 ( 17S 'ew c <br /> L Operator's Name Address <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 /> r <br /> ALL APPLICANTS: <br /> 2. HOUSING Total Employees Including Operators <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 C <br /> Sewage Disposal Method ! ! r <br /> Solid Waste Disposal Method <br /> Water Supply Source <br /> Anjr/1 Waste Disposal Method <br /> d. � CONSULTATION FEE 7,06 - '� -•� �bBU81� y�ESS LICENSE MAY .2 - ) <br /> 7. PLAN CHECKING FEE 3 Dli ❑ pANCE PERMIT <br /> I. REAL ESTATE ENV-'- . °. 1,. •_TH <br /> REQUEST: Water Well Inspection❑ Sample❑ Title Company )'P4 ;l /JLI<�I ES <br /> Sewage System Inspection ❑ Address_ <br /> Tele. No. <br /> Escrow No. <br /> Seiler Seller Address <br /> Telephone No. Seller Agent Name <br /> Service Request For Dote <br /> I hereby certify that I have prepAred this application rd',hat the work will be done in accordance with San Joaquin County <br /> ordinances, state laws and sales and regulations pf t an <br /> Joaquin Local Health District. <br /> APPLICANTS SIGNATURE Xr �'/ /j �e-•� /I / ' f'' f i/ //O 1 <br /> Title `/ e Dale I / -W <br /> __- <br /> / FOR DEPARTMENT USE ONLY t� <br /> Fee Is DW13: ANNUALLY �� <br /> / ❑ PER UNIT PER SITE (EACH ❑ January 1 6 Received By January 31 ,❑Uuly 1 b Received By July 31 <br /> BILLING j REMIT <br /> ILLING RE <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMJUNT <br /> FEE D�6 os LSU <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> OTHER m <br /> -1 n <br /> 0 <br /> Retwetl by Date Reca,pt No. Permit No Issuance Date Aleded Oelrvere0 � <br /> I <br /> —RRT3a1M,ALLCOa11s.TQ: El1VIa0lIMEMTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTOM AVE.,P.O.Box 1006 tTOCKTOM,CA 96201 m <br />