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A Oil When Submitted Property Completed. Be Sure T11 Sigro The Application. <br />SAN I 'LCL HEALTH DISTRICT GENERAL <br />ENGINEER'S AND/ORIF VEHICLE INVOLVED, GIVE <br />APPLICANT'S AND/OR Make <br />CONTRACTOR AND/OR ENVIRON ENTAL HEALTH PERMIT/SERVICES �— <br />BROKER AND/OR Lid. No. <br />LICENSE AND/OR FOOD ESTABLISHMENT& HOUSING RIst. No. <br />REGISTRATION M Regist. SAMPLING g — <br />NUMBER REAL ESTATE INSPECTIONS Color <br />POULTRY RANICNES AND KENNELS <br />MISCELLANEOUS MVICES � <br />`Application Date _Business/ ame To Appear On r i4 l <br />a — -- <br />ie Type Permit/Service Req ested r <br />Applicant Name —s—ress S S 7,r <br />_ Business Telephone o. Emergency Telephone No. <br />Property Location/Address r <br />Property Owner Address 0 Wr %`,o <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 />13 FOOD PROCESSING PLANT ❑'COMMISSARY ❑ ICE PLANT ❑ BAKERY <br />❑ ROADSIDE FOOD STAND ❑ .I000R STORE ❑ BAR 13 ITINERANT RESTAURANT <br />CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br />13 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 />. HOUSING <br />HOTEL/MOTEL/No of Units 13CERTIFICATE OF OCCUPANCY <br />MOBILE HOME PARK/No. of Spaces <br />3. WATER QUALITY ❑' WATER SAMPLE (Bacterial) 13CHEMICAL <br />13 PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY 13WATER HAULER <br />NO. OF PUBLIC SERVED (Connections) <br />4. RECREATIONAL HEALTH ❑ SWIMMING; POOL ❑ SPA ❑ WADING POOL ❑ NATURALBATHING PACE <br />S. VECTOR CON OL ❑ 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 />S. 13CONSULTATION FEE ❑ BUSINESS LICENSE <br />7. ❑ PLAN CHECKING FEE ® DANCE PERMIT <br />R. REAL ESTATE <br />REOUEST Water Well Inspection 13 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 an g ions of t 'e San Joaquin Local Health Distract. <br />APPLICANT'S SIGNATURE X Title $r'. Date <br />FOR DEPARTMENT USE ONLY <br />F IS Due: ❑ANNUALLY ❑PER UNIT ❑PER SITE ❑EACH ❑ `Janus 1 8 Received $y January 31 - ❑July 1$ Received By July 31 <br />W <br />- C <br />a <br />Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br />APPLICANT—R ,ALL TO: 9MUWUMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE., P.O. Sox 2009 STOCKTON CA 96MI1 st <br />a . <br />DATE <br />s <br />a <br />SIS <br />W <br />- C <br />a <br />Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br />APPLICANT—R ,ALL TO: 9MUWUMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE., P.O. Sox 2009 STOCKTON CA 96MI1 st <br />