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Applications Will Be Pr When Submitted properly Completed.. Sure To Sign The Application. <br /> J UI LOCAL L DISTRICT GENERALENGIN ' <br /> APPLICANT'S <br /> AND/OR <br /> PLL, ' IF VEHICLE INVOLVED,GIVE <br /> aPPLtCANrs AND/oR <br /> CONTRACTOR AND/OR ENVIRON ENTAL HEALTH PERMIT/SERVICES ` Make <br /> BROKER AND/OR Lic. No. _ <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,HOUSING Regist. No. <br /> REGISTRATION PUBLIC POOLS, PATER SAMPLING g -- <br /> NUMBER REAL ESTATE INSPECTIONSColor_ <br /> POULTRY RANCHES AND KENNELS <br /> r` MISCELLANEOUS SERVICES f <br /> rA lication Date dd <br /> I Pp �� Bus'��/Name To ppear On Permit <br /> Type Permit/Service Requ ted: /° � <br /> Applicant Name ' �7 �"f Address -- <br /> u Emergency Telephone N . �/V 22 <br /> Property Location/Address <br /> `Property Owner l' _ _ Address ® ,-fox' 6` , <br /> L Operator's Name 5 Addressr�l e <br /> 1. FOOD ESTABLISHMENTS Total Building Sq.Footage Restaurant,Maximum Seating Capacity <br /> ❑ RESTAURANT 13 FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> 13 FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND 13 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 /> 11 FOOD CROP HARVESTING/No.of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING <br /> 13 HOTEUMOTEUNo.of Units CERTIFICATE OF OCCUPANCY <br /> 13 MOBILE HOME PARK/No.of Spaces <br /> 3. WATER QUALITY 13WATER SAMPLE(Bacterial) ❑ CHEMICAL <br /> 13 PUBLIC WATER SYSTEM 0 SURFACE WATER SUPPLY 13WATER HAULER <br /> NO.OF PUBLIC SERVED(Connections) <br /> 4. -RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA' ❑ WADING POOL >-❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL 13 POULTRY FARM/Maximum No.of Birds <br /> 13 KENNEUunways -- /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 /> O. 15 CONSULTATION FEE ❑ BUSINESS LICENSE <br /> T. 14zjPLAN CHECKING FEE DANCE PERMIT <br /> S. REAL ESTATE r <br /> REQUEST: Water Well Inspection 0 Sample 13 Title Company <br /> Sewage System Inspection 13 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 hat l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,s_ ws,and rules andreguI tions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATUR ,Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS DUMB; ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1$Received By January 31 ❑July 1 8 Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE fJc� <br /> LESS <br /> PRORATION af <br /> PLUS <br /> PENALTY / <br /> OTHER <br /> a <br /> OTHER ^� <br /> n <br /> 8 ... <br /> /®-' <br /> Received by Date pt No Permit No. Issuance2a Mailed Delivered i <br /> APPLICANT—RE .AW TO: ENVIa TAL HEALTH PERMIT/SERVICES 1601 E.HAZE6 E.,P.O.Box 2009 STOCKTON,CA 95201 W <br />