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Applications WIII Be P> .essed When Submitted Properly Completed.Be Sures Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENOINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/ORMake -- <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Lic. No. -- <br /> BROKER AND/OR FOOD E=TASLISMMENTIL MOUSING <br /> LICENSE AND/OR ►BOLI:POOLE,WATER SAMPLING Regist. No. - <br /> REOISTRATION REAL ESTATE INSPECTIONS Color — — <br /> NUMBER <br /> ►OULTRT RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> rApplication Date-/ten`�rc,� Business/Name To Appear On Permit 1T)'.ji _ `/ r- <br /> Type Permit/Service Requested: ���� G 17 f' — --- <br /> Applicant Name Z;I^' �xZL� `aC- ti''<�- c�"l t� 7�/� Address ---3ZC-) �� ( � 0��^ <br /> _._ Business Telephone No. 20ci 4 G,'`("'' �''> S-- Emergency Telephone No. <br /> (Property Location/Address ! (2v(, <br /> IProperty Owner r-0-5;,� �'i� Address 2-2 i I(x/(- <br /> L Operator's 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 ❑ 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 SDM3S/11Wb3d <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPAN14)LIV3H 1d1N3WN0MN4 <br /> ❑ MOBILE HOME PARK/No.of Spaces <br /> 9. WATER QUALITY ❑ WATER SAMPLE(Bacterial) ❑ CHEMICAL PF 6[ N n r <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 PLlQla�. A 13 7 3 a <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds 1 N 3 IN A V d <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. E CONSULTATION FEE- —� C/ BUSINESS LICENSE <br /> 7.111kKAN CHECKING FEE ❑ DANCE PERMIT <br /> 8. 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 11have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state lawt,and les a tions of the San Joaquin Local Health District. �y <br /> APPLICANTS SIGNATURE X Title �-��,�C-F�� Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑July 1 &Received By July 31 <br /> BREMIT <br /> BILLING REMITTANCE' $ <br /> BASE EXPLANATION REMITTED AMOUNT DUE CHECKED <br /> GATE GATE AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> f <br /> OTHER <br /> Ilk o <br /> T 1� <br /> Recei by Dalk Receipt No. Permit No. Issuance Date Mailed Delivered i <br /> A ICANT—RETURNALL.COSJELTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,.P.O.Boa 2009 STOCKTON,CA 05201 1W <br />