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Applications Will Be Pr When Submitted Properly Completed. Be Sure Sign The Application. <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR <br /> APPLICANT'S AND/OR APPLICATION IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make _— <br /> BROKER AND/OR Lic. No. __— <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,MOUSING <br /> REGISTRATION PUBLIC POOLS,WATER SAMPLING Regist. No. <br /> NUMBER REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> J MISCELLANEOUS SERVICES t 1/ <br /> FApplication Date r 21-9)"d Business/Na a To Appear On Permit (1U) 7 1_ <br /> 4*Type Permit/Service Requested: )�'' 1. _ <br /> Z <br /> Apph a t Name F Lz[K 1 [ �. �� Address J 1 <br /> Business T le hone N - Emer ency Telephone N�. <br /> i Property Location/Address' KaV lIV 114,6 / _ <br /> <Property Owner a U1 14 S'�Q _ Al6dress <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 /> ❑ 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 /> 6. 6 CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. JM PLAN CHECKING FEE 36-,06 ❑ DANCE PERMIT <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample❑ Title Company <br /> Sewage System Inspection ❑ Address_ Tele. No. <br /> Escrow No. <br /> s <br /> Seller Seller Address <br /> Telephone No. Seller Agent Name <br /> Service Request For D to <br /> I hereby certify that I ave prep d this appiicati n d that the work will be done in accordance with San Joaquin County <br /> ordinances,state law ,and r and regulations a San Joaquin Local Health District. <br /> APPLICANT'S SIGNATU _ Titl Date-l-L-7-1-a' 411 <br /> FORD PARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY./)OPER UNIT PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE' $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER O 2-3o <br /> a <br /> OTHER m <br /> VP <br /> Received by Datea pt No. Permit No. Issuanc a Mailed Delivered <br /> S <br /> APPLICANT—RETLRN.ALI.COPAESTO: ENV ENTAL HEALTH PERMIT/SERVICES 1601 E.HAZE VE.,P.O.Boa 2009 STOCKTON,CA 95201 w <br /> Y <br />