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Applications Will Be Pryomoeed When Submitted Properly Completed.Be Sure`e,V.ign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> "OR APPLICATION IF VEHICLE INVOLVED, GIVE <br /> AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make —_ <br /> J/OR <br /> Lic. No. <br /> AND/OR FOOD ESTABLISHMENTS,HOUSING Regist. No. <br /> RATION PUBLIC POOLS.WATER SAMPLING 9 <br /> BER REAL ESTATE INSPECTIONS Color _ <br /> _ POULTRY RANCHES AND KENNELS <br /> ' MISCELLANEOUS SERVICES }� <br /> (rPlication Date Business/N a To Appear On Permite Permit/Serv'ce Rquested: /licant Name - 1-I I Adddress_f c 6 �28 si ess Te1e�o No. / �U Emergency Telephone No! � 'ypety Location/ ddresperty Owner_ C Address 5 L <br /> _ <br /> . L Operator's Name C P Address r C b <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage <br /> -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 /> ? ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING <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 Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> 6. CONSULTATION FE ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> REAL ESTATE <br /> REQUEST: Water Well Inspection❑ Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <br /> ''''"_ Escrow No. <br /> Seller <br /> ..__ Seller Address <br /> Telephone No. Seller Agent Name <br /> ., <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 /> 4a_ ordinances,state laws, d rules a �egulquin Local Health District. <br /> ' APPLICANTS SIGNATOR X Titlef�1(/�}Y ' �- Date <br /> u <br /> FOR DEPARTMENT USE ONLY <br /> d Fee is Due.❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 3 Received By January 31 ❑ July 1 3 Received By July 31 <br /> BILLING $ REMIT <br /> ILLING REMITTANCE*s w BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> ' LESS ,l <br /> PRORATION <br /> S OTHER <br /> s OTHER m t <br /> Received <br /> o L <br /> by F Date Receip Permit No. Issuance Date Mailed Delivered = F <br /> APPLICANT—RETURMAL11-Cr+emn TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA 95261 W i <br /> F. <br />