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;hen <br /> Applications Will Be P eased Submitted Properly Completed. Be Su�o Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br /> BROKER AND/OR Lic. No. <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> REGISTRATION PUBLIC POOLS,WATER SAMPLING Regist. No. <br /> _ NUMBER j-jk-:;6 REAL ESTATE INSPECTIONS Color <br /> G� POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS <br /> SERVICES <br /> rApplication <br /> 'Date B sine Name Ta pear O -__— <br /> ,aType Permit/Service este __ <br /> Applicant Name .� SSdZY �2 _�A/ddress -- <br /> - Business Telephone N, Emergency Telephone No. — <br /> Property Location/Address_-'Cy <br /> JProperty Owner Address — <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 /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds <br /> ❑ KENNEL/Runways /Animal Population No. _ No.of Confining Cages <br /> Sewage Disposal Method Y <br /> Solid Waste Disposal Method <br /> Water Supply Source 4 Animal Waste Disposal Method <br /> 6. 13 CONSULTATION FEE - ' l71 , l*e ❑ BUSINESS LICENSE <br /> 7. E PLAN CHECKING FEE 0a M211 ❑ DANCE PERMIT <br /> 8. REAL ESTATE � <br /> REQUEST: Water Well Inspection J 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,and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE Xri��` �'� _ Title 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 /> REMIT <br /> BILLING REMITTANCE' E <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> " AMOUNT <br /> FEE r � ( O <br /> ZL. <br /> LESS <br /> PRORATION <br /> PLUS ? <br /> PENALTY <br /> OTHER <br /> � v <br /> m <br /> OTHER <br /> r <br /> i <br /> C" a <br /> Received by Dateeipt No. Permit No Isa tuAMElhao Mailed Delivered = <br /> APPLICANT—RETLUMALLCORA TO: MENTAL HEALTH PERMIT/SERVICES 1Q01 E.H N AVE.,P.O.Box 2009 STOCKTON,CA 95201 w <br /> L1 K <br />