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Applications Will Be Pr d When Submitted Properly Completed. Be S fo Sign The Application. <br /> S JOAQUIN LOCAL HEALTH DIS CT GENERAL <br /> w D/OR APPLICATION IF VEHICLE INVOLVED, GIVE <br /> T'S AND/OR Make <br /> CTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES -- <br /> AND/OR Lic. No. -- <br /> E:AND/OR FOOD ESTABLISHMENTS,HOUSING Regist. No. <br /> ,TRTION PUBLIC POOLS,WATER SAMPLING g <br /> ER. REAL ESTATE INSPECTIONS Color _ <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> tion Date S -16 -94 _ Business/Name To Appear On Permit _ � �� _ USA int <br /> rmit/Service Requested: _ _— <br /> t Name •J 14 V/4-/L Address 2- <br /> Business <br /> Business Telephone No. Emergency Telephone No. — <br /> rty�Location/Address 4QQ 0 loy�'1'i�2C o o A�I Zz> _ <br /> erty Owner Cct-Cnt,0N V4 A — 1-Raw , RWj4ISk Address <br /> Aerator's Name , off Fr�Z l� Address �y t9Ci W AT c i r.u � . 7k- 1 <br /> 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 /> OOD CROP HARVESTING/No.of Field Employees <br /> APPLICANTS: Total Employees Including Operators <br /> .OUSING <br /> kOTEL/MOTEL/No.of Units ❑ CERTIFICATE OF OCCUPANCY <br /> OBILE HOME PARK/No.of Spaces <br /> ATER AUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> BLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> F PUBLIC SERVED (Connections) <br /> REATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> OR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> KENNEu`Runw`ays /Animal Population No. _ No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> 'Nater Supply Source Animal Waste Disposal Method <br /> 8. CONSULTATION FEE ❑ BUSINESS LICENSE <br /> T. PLAN CHECKING FEES, oo ❑ DANCE PERMIT <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ 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 thisilaRlication and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rules and regu atio of the S Joaquin Local Health District. <br /> APPLICANT'S SIGNATUR X _ Title �`��"�C� Date S 5 ` <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY C3 PER <br /> U T 11 PER SITE El 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 /> p p <br /> FEE �-7 O <br /> 6. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER keG <br /> OTHER <br /> W Add <br /> ' Receigd b�y}�-q�� Date Permit No. Issua to Mailed Delivered <br /> APPLICAN"T..,"'�—" ALL ORMSTO. ENVIEjLNo. <br /> HEALTH PERMIT/SERVICES 1601 E.HAZEL AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />