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Applications Will Be I"Osed When Submitted Properly Completed. Be Sur 4ign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANTS AND/OR Make - <br /> -- <br /> CONTRACTORAND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Lic.No. --- <br /> BROKER AND/OR <br /> LICENSE AND/OR F000 ESTABLISHMENTS.HOUSING Reg ist. No. --- <br /> REGISTRATION PUBLIC POOLS WATER SAMPLING — <br /> NUMBER __.. ___._ _ REAL ESTATE INSPECTIONS Color— <br /> POULTRY RANCHES AND KENNELS <br /> 44 ((11 MISCELLANEOUS SERVICESM�y�I <br /> rApplication Date_V=I_V.-�� _- Business/Name To Appear On Permit - <br /> *TYPe Permit/Service Requesletl:` L1(_�A16� - -U F._ urf Cif 000Yr�h+__W <br /> Applicant Name �P�4%33-NAddress <br /> Business <br /> TBusiness TelepIn a No. gZL" /Emergency Telephone No. - — <br /> (Property Location/Address <br /> d Property Owner J hl117lL y_- -V- 't-�Li ry- Address 44OL. f}�G 4�'ti'A�< De <br /> L Operator's Name J,iM'j,`ALTJreDYl '�(L- —L-E� X7F Address h <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 /> ❑ HOTEL/MOTEL/No.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 /> ❑ 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 /> B. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. ❑ 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, <br /> q�and rules and regulations of the San Joaquin Local Health District. [,/ <br /> APPLICANT'S SIGNATURE X�Y_. r _ Title �Li.� A `N Date-0- <br /> U <br /> ap <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 8 Received y July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> ) DATE DATE REnMITTED AMOUNT <br /> FEE <br /> PRORATION A <br /> PLUS V <br /> PENALTY <br /> OTHER <br /> OTHER -- <br /> �!a �— I`1" �P a3 - - <br /> Received by Date Receipt No, Permit No. Issuance Date Mailed Delivered t <br /> APPLICANT—RETUMALL-CORIESTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bos ESM STOCKTON,CA 95201 w <br />