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Applications WIN Be hoCeeeed when subn*W prop"Comple/ed.Be Sure To Sign The ApPNeeHon- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> APPLICATION IF VEHICLE INVOLVED,GIVE <br /> oR ENVIRONMENTAL HEALTH PERMIT/SERVICES ALid.No <br /> BROKER AN MA <br /> OX0 NIM UTAMgIIII OM IltistiM <br /> REGUF E ANGOR PSMN FM &WA10 SAMFtIM Kegler.NO. <br /> REGtsTRATION <br /> N1OASER KAL HIIITFS�TABANC=AM C-?*ALL�l L) Color <br /> tiE11111CfS t1 <br /> (Application Date Business/Name To Appear On Permit f <br /> ,Type Permit/Service Requested: <br /> Applicant Name A rew 9' R (!) 1 <br /> tZ _ usin Telephone N Emergency Telephone No. <br /> Property Location/A dress ` ( 3 rtG r tr <br /> Property Owner Address e <br /> L Operators Name . Address <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 ❑ LIOUOR 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 Operator <br /> L HOUSING <br /> ❑ HOTEUMOTEL/No.of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.Of Spaces <br /> & 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/Runwsys _ /Animal Population NO. No.of Confining Cages <br /> Sewage Disposal Method _ <br /> Solid Waste D"Method <br /> An <br /> Water Supply SOurw knal Wash Disposal Method <br /> L ❑ CONSULTATION FEE 1 ❑ BUSINESS LICENSE <br /> T. 9 PLAN CHECKING FEE DANCE PERMIT <br /> L REAL ESTATE <br /> REQUEST: Water Well Inspection ' Sample 13 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 Data <br /> 1 hereby certify that I hes Anspared thisal icatlon and that the work will be done In accordance with San Joaquin County <br /> ordinances.state ions of the San Joaquin Local Health District <br /> APPLICANTS SIGNATUR X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee b Due:❑:SLY•• O PfR. ❑PSR sm' .O EACH ❑ Jorwory 1 a Awsh, esy,lnllr.ry at Q.IYly.1 a R.owWW sY Aug 31 <br /> REMIT <br /> BASEE%PLANATION BILLING REMITTANCE Z AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE C�l�jU. <br /> LESS <br /> PRORATION <br /> PLS ; <br /> PENALTY <br /> OTHER <br /> OTHER D <br /> 1 f <br /> �1100 <br /> Roceeww by o.1. A9060 No. Pemr11 No. .w Dole Mailed DotftwW = <br /> APPUCAIrT—R[riRMALLOOMa TO: lr4MONaQNTAL HEALTH P[IIYfTAE11V10Ea Isola. -_LTO"AVC.P.O.Ms 21100 STOCKTOK CA 911291 Y <br />