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- Appllcetlons WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> SAN JOAQUINLOCAL <br /> HFAI TH DISTRICT <br /> ENGINEER'S AND/OR GENERAL <br /> APPLICANT'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> CONTRACTOR AND/OR <br /> BROKER AND/OR NVIRONMENTAL HEALTH PERMI RVICES Make _ <br /> LICENSE AND/OR NG Lic. NO.REG <br /> NUMBERPUBLICPUBLIC POOL&WATER SAMPLING Regist. No. ___ <br /> REAL ESTATE INSPECTIONS COIOr_ <br /> POULTRY RANCHES AND KENNELS r'3 JI .. � <br /> Application Date Z �oI <br /> POULTRY RANCHNEOUS SERVICES 4_C rTv 1V <br /> Business R/Name To Appear On Permit -STS 2N CE2 sE <br /> F Type PermiVService l (�� �� --�-5 ' --- <br /> i Applicant Nam K.N 1 y\� ���GE's�Dne .. <br /> A'-did-re—s-s L y1� 1ytt�Q <br /> c►a GS42�L e - -- -Tom___.. <br /> Business Tele hc1—F'5 -!C 1I Emergent Telephone No. "M�- <br /> Property Locationddress ) )(}}•( � 5_ �� / x <br /> i Property Owner M• K j"'(L _ Address_��m t- - �h'c <br /> L Operator's Nam rbgL I Q Y A J12 jQ,! Address 51y'�fC <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 <br /> 0 ITINERANT <br /> 13CONFECTIONARY STORE 13FOOD SALVAGER 1:1 FOOD DEMONSTRATION 11 FOOD VENDOR RESTAURANT <br /> 13VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT 11VENDING VEHICLE ` <br /> 13 FOOD CROP HARVESTING/No.of Field Employees r <br /> ALL APPLICANTS: Total Employees Including Operators I <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No.of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER g ❑ WATER SAMPLE(Bacterial) 13 CHEMICAL <br /> 11 <br /> PUBLIC WATERATER SYSTEM 11 SURFACE WATER SUPPLY ❑ WgTER HAULER <br /> NO.OF PUBLIC SERVED(Connections) <br /> a. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds <br /> ❑ KENNEVRunways /Animal Population No. _ N <br /> Sewage Disposal Method o.of Confining Cages <br /> Solid Waste Disposal Method <br /> — <br /> 6 Wate,Supply Source Animal Waste Disposal Method _- <br /> �CONSULTATION FEE .S'r Da ❑ BUSINESS LICENSE _ <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> S. REAL ESTATE — - <br /> REQUEST: Water Well Inspection 13 Sample❑ Title Company <br /> Sewage System Inspection ❑ Address <br /> Escrow No. _ Tele. 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, ules and regulations of the San Joaquin Local Health District. <br /> APPLICANTS SIGNATURE X �/ <br /> _PS <br /> Title w M S . Date 7 1-2-1 8S <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH <br /> ❑ January 1 S Received By January 31 ❑ July 1 8 Rtteived By July 31 <br /> BASE EXPLANATI G REMITTANCE' S REMIT <br /> ATE REMITTED AMOUNTDUE CHECKED <br /> FEE <br /> AMOUNT <br /> 7 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Rttewatl try .10 Re'..PI No. Permu No. <br /> APPLICANT— Itauance HADals Mailed Delivered o <br /> aETLIBYJU.LCpaYS TO: ENVIRONMENTAL HEALTH PERYIT/SERVICES last E. EELTON AYE.,►.O.Boa MOs sTOCKTON,G fSE01 <br /> W <br />