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Applications Will Be Pr e�ssed When Submitted Properly Completed.Be Sure T Soo, <br /> Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/ORMake -- <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Lid. No. -- <br /> BROKER AND/OR FOOD ESTABLISHMENTS.HOUSING _ <br /> LICENSE AND/OR PUBLIC POOLS,WATER SAMPLING Regist.No. <br /> REGISTRATION REAL ESTATE JUPECTIONS Color <br /> NUMBER POULTRY RANCHES AND KEN <br /> MISCELLANEOUS SERVICES <br /> Application Date E <br /> am- Business/Name To Appear On Permit _ C� — L�-�y-- <br /> Type Permit/Servic , u Ste :YyUU "�ODUA lican Neme Address �Q` <br /> _ Bus ess Telephon mergency TelepF�one o. <br /> Property Location/ ddrA ess �i► S-� <br /> {Property Owner F� Address <br /> LOperator's Name _ �" �� Address ��� - <br /> 7 <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Seating Capacity <br /> d 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 /> ❑ HOTEUMOTEUNo.of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces <br /> 3. WATER.AUALITY ❑ 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 <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 FEE ❑ BUSINESS LICENSE <br /> T. ❑ 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 ealth District. <br /> APPLICANT'S SIGNATURE Title ?OL!?j Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 5 Received By January 31 ❑ July 1 a Received By July 31 <br /> REMIT <br /> S <br /> SASE EXPLANATION BILLING REMITTANCE' CHECKED <br /> DATE DATE REMITTED AMOUNT DUE <br /> ,(� AMOUNT <br /> FEE 40, eQ� / Ill, A <br /> LESS <br /> PRORATION 3�rOi O 0 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> n <br /> 0 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered 9 <br /> I <br /> APPLICANT—RETURNALLCAMIESTO. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.son 21109 STOCKTON,CA 115201 W <br />