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Applications Will Be11111—rocesssd When Submitted Property ComPleted.8e S3Ko Sign The Appltcallon, <br /> AN JOAQUIN LOCAL HEALTH DIS ICT GENERAL <br /> ENGINEERS s AND/OR <br /> APPLICATION IF VEHICLE INVOLVED,GIVE <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br /> BROKER AN41DR ^— <br /> LICENSE ANDIOR FOOD EETARLINIIMEKM Iidumns Lid.No. <br /> REGISTRATION EUNLIC ML&WATER"ASPUNR 'i Regist.No. <br /> NUMBERREAL,E3TATEINNPECTWU - Color <br /> POULTRY RAXCHEN ANR ItENN <br /> MUIt:ELLANEOtii ifritC" <br /> APPlication Date Q Business/Name To A <br /> `-' � ppear On Perini O NLO/U I <br /> rTYPe PermiVServiC R es ted G�-t - / T,4 <br /> Applicant Name Addr G <br /> Business Telephone No._` ^,A Emergency Telephone No, <br /> Property Location/Address € <br /> iProperty Owner C- Z&A 4f NIdmv , Address ,rs%7i <br /> L Operators Name Address <br /> I. FOOD ESTABLISHMENTS Total Building Sq.Footage Restaurant,Maximum Seating Capacity <br /> © RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT 13COMMISSARY 13ICE PLANT I ❑ BAKERY <br /> ❑ ROADSIDE.FOOD STAND ❑ LIQUOR STORE ❑.BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MACHINEWNo.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 /> ❑ M081LE 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 r <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds <br /> ❑ KENNEL/Rumrays /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 FEE ❑ BUSINESS L10EidSE' <br /> T. PLAN CHECKING FEE_ ❑ DANCE PERMIT L <br /> IL REAL ESTATE <br /> REQUEST: Water Well Inspection Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tele. Na. <br /> Escrow No. <br /> Seller Seiler Address <br /> Telephone No. Seller Agent Name <br /> Service Request For Date <br /> ii <br /> I hereby certify that I h red this applicatlo and that the work will be done in accordance with San Joaquin County <br /> ordinances.state Saws. ru and Is ns o Joaquin LOOM District <br /> i�C1/ <br /> APPLICANTS SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT' ❑ PER SITE ❑EACH Q January 1 a Received By January ❑JuIY 1 A Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE' = REMIT <br /> AMOUNT DUE CHECKED <br />- DATE DATE RpurrTED <br /> AMOUNT <br /> FEE <br /> LE$$ <br /> PRORATION <br /> Pun <br /> PENALTY <br /> OTHER <br /> OTHER + <br /> HaceireebyDae Recaipt NO. Aermlt No. Issuance Dots Malbd Delivered <br /> APPLWANT—ftrTL0 ALL.COs?rE$iQ DMIRONIIENTAL HEALTH PERMIT/SERVIMS ism E.HAZELTON A s - <br /> . YE,P.O.Deet 2s0! iTOCKTOr�CA�Z'. rr <br />