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i <br /> Applications Will Be PAnd When Submitted Properly Completed.Be Sure ign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTGENERAL <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR Make --- <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> BROKER AND/OR Lic. No. <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,HOUSING Regist. No. <br /> REGISTRATION PUBLIC POOLS,WATER SAMPLING ------ <br /> NUMBER REAL ESTATE INSPECTIONS Color --- <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> Application Date % usiness/Name To Appear On Permit ---- <br /> aType Permit/Service Requested: -- <br /> `Applicant Name �'�� ddress <br /> g _ Busin_e5s Telephone Nom, 11-f, Emergency Telephone No. <br /> <Property <br /> -`' Location/Address.-.-..- <br /> Property Owner � �� /�`� df�P• 3t°Address <br /> L Operator's Name fjZ,- ea <br /> --- — <br /> — <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Seating Capacity <br /> RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> 13 FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> 13 ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> 13 CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> 13 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 /> MOBILE HOME PARK/No.of Spaces <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> PUBLIC WATER SYSTEM 13 SURFACE WATER SUPPLY ❑ WATER HAULER <br /> N .OF PUBLIC SERVED (Connections) <br /> 5. RECREATIONAL HEALTH 13 SWIMMING POOL 13 SPA 0 WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL 0 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 /> i Water Supply Source Animal Waste Disposal Method <br /> CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. 0 PLAN CHECKING FEE _ ❑ DANCE PERMIT <br /> a. EL ESTATE �� �B <br /> REQUEST: Water Well In tion❑ Sample❑ a itilompany <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 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rules and regul tions of San Joaquin Local Health District. c <br /> APPLICANT'S SIGNATURE Title - Date Z a <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 /> BASE EXPLANATION BILLING REMITTANCE' $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE f <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> �*01A <br /> OTHER / <br /> a <br /> OTHER <br /> k o <br /> Received by Date jaeipt No- Permit No Issuenc to Mailed Delivered i <br /> A ICANT—RET ALL TD: EN ENTAL HEALTH PERMIT/SERVICES 1601 E.HA2 AVE.,P.O.Box 2009 STOCKTON,CA 95201 w <br />