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Applications Will Be ProBeased When Submitted Properly Completed.Be Sure lVaSign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR Make <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES _--- " <br /> BROKER AND/OR LIC. NO. -- <br /> LICENSE AND/OR FOOD ESTABLISHMENT&HOUSING Re ISI. NO. <br /> REGISTRATION PUBLIC POOLS TE <br /> MAN SAMPLING 9 - <br /> NUMBER '�7'{"-ADC+ REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> r-�� MISCELLANEOUS SERVICES <br /> rApplication Date 42`�gBusiness/Name To Appear On Permit <br /> eType Permit/Service Requested: 4t-' - _ X00 F <br /> Applicant Name " _2 Address ' <br /> ddd 44c�'l-2v ( - pL,99 _Business Telephone No. '5�6�f�Oc9ft' Emergency Telephone No. 5`^-T - <br /> Property Location/Address <br /> iProperty Owner Address 4/7 <br /> L Operator's Name 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 <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 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 /> ❑ KENNEURunways /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water, ply Source Animal Waste Disposal Method <br /> CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> N. 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 1 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 /> APPLICANTS SIGNATURE X _ Title /9/c"✓ar / Date <br /> TJ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 A Re elved By July 31 <br /> REMIT <br /> BILLING REMITTANCE f <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> • AMOUNT <br /> FEE 0o <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receivy <br /> Data 6J Receipt Na. Permil N. (Nuance WN Mailed Denoted i <br /> APPLICANT-RETMaNALI.COMAS VM EMYIOONM[NTAL HEALTH PERMIT/SERVICES IMI E NAZELTON AVE,P.O.I w MIM STOCKTON,CA Tafel w <br />