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Applications Will Be End When Submitted Properly Completed.Be Sur ign 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 /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES' -- <br /> BROKER AND/OR Lid. No. -- <br /> LICENSE AND/OR FOOD ESTAMMMENT&HOUSING " <br /> REGISTRATION WATER SAMPLING Regist. No. _ <br /> NUMBER REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> rApplication DateBu ' eC <br /> ss/Nam T,�Appear On Per 't <br /> Type Permit/Service Requested: � ` <br /> Applicant Name Address �a�f� <br /> Busine s Teiep e N ��-�g E a cy Telephone Nc � � k <br /> Property location/Addy ss <br /> Property Owner 4 r 2 '® Address !F-Af-� <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 /> 13 ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> 11 VENDING MACHINES/No.of ❑ MOBILE FOOD PREP.UNIT ❑ VENDING VEHICLE <br /> 13 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 /> 13 MOBILE HOME PARK/No.of Spaces <br /> 3. WATER QUALITY ❑ WATER SAMPLE(Bacterial) ❑ CHEMICAL <br /> 13 PUBLIC WATER SYSTEM 0 SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO.OF PUBLIC SERVED(Connections) <br /> 4. RECREATIONAL HEALTH 13SWIMMING POOL ❑'SPA 13WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL 13 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 /> S. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. PLAN CHECKING FEE ❑ DANCE PERMIT <br /> S. 'REAL ESTATE <br /> REQUEST: Water Well InspectionE3 Sample Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <br /> Escrow No. <br /> Seiler Seller Address <br /> Telephone No. Seller Agent Name <br /> Service Request For Date "T <br /> 1 hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws and rules a d regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due:❑ ANNUALLY r ❑ PER UNIT ❑ PER SITE ❑EACH ❑ January 1&Received By January 31 ❑July 1,&Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE' $BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> e <br /> OTHER <br /> SoS <br /> 0 <br /> s <br /> Received by Date Receipt No.' Permit No. Issuance Date Mailed :Delivered Z <br /> APPLICANT—RETWMALLOORMSTO.. ENVIRONMENTAL,HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA UM41 <br />