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Applications Will Be Proces When Submitted Properly Completed.Be Sure0Sign The Application. <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANTS AND/OR Make - --- <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> u BROKER AND/OR LIC. No. -- <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,HOUSING Regist. No. <br /> REGISTRATION PULLIC POOLS,MATER SAMPLING - <br /> NUMBER REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> / MIS NEOUS SERVICES. ,J <br /> [Application Date `1.� h Business/Name To Appear On Permit /Vey `'�/��/�-/ !� <br /> FType Permit/Service Requested: " e—O01, J% AC T,1g�/,� `��� ir, <br /> Applicant Names dIL�,Lnu �.or!lil .. S-/a�id.E. F Address l2_ /V,Oem L40V!6^' - <br /> u ��X S,c -_ Business Telephone No. G1�z_UR 7�� Emergency Telephone No. <br /> Property Location/Address AIIC'dL <br /> i Property Owner now z;oOPu 2rl*L Address 3 '�3O /r1L�/11 oltp _ <br /> L Operator's Name 5-4An e 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 r <br /> ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No.of Field Employees I <br /> ALL APPLICANTS: Total Employees Including Operators f ,t <br /> 2. HOUSING �Q f' )JA <br /> . /J <br /> ❑ HOTEL/MOTEL/No.of Units ❑ CERTIFICATE OF OCCUPANCY <br /> 11 MOBILE <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 /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds e <br /> / <br /> ❑ KENNEL/Runways /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> O. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> S. 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 /> 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 rules and regulations of the San Joaquin Local Health District. <br /> �� L <br /> APPLICANT'S SIGNATURE X _ Title /}�E J7�ll/17 Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 It Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> �..{� r�r AMOUNT <br /> FEE ,� I �T O 'G]O <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> f <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered i <br /> APPLICANT—RETURMALL.CORMaTM ENVIRONMENTAL HEALTH PERMIT/SERVICES 18111 E.HAZELTON AVE.,P.O.Sent OHIO STOCKTON,CA R5E01 W <br />