Laserfiche WebLink
Applications III Se Pro" W mitt Properly Completed.Be Sur4Tgn The Application. <br /> LOCALSAN JOAOUIN HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR Make <br /> ONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES — <br /> ROKER AND/OR Lic. No. <br /> ICENSE AND/OR FOOD ESTAOLISN ENTS,I#OUSING RegistNo: <br /> REGISTRATION PUBLIC MATE SAMPLING . --.� <br /> BER REAL ESTATEf PEC Color <br /> POULTRY RANCNfS AND KENNELS �- <br /> MISCELLANEOUS SERVICES <br /> lication Date Business/Name To Appear On Permit _ 4 f1S t v1 e ic,n <br /> Perlrlit/Service Requested: —_—__/ - a -- — <br /> t Name C ®N _address—_ tf 1 .J�_noh ��fQYvr�rt�� et, <br /> sin one No.alc_ ` Emergency Telep a No. _. <br /> y location/Addres <br /> y Owner _ Address c 1 t ol-N <br /> or's'Name - Address <br /> OD ESTABLISHMENTS Total Building Sq.Footage Restaurant,Maximum Seating Capacity <br /> STAURANT 13-FOOD MARKET RETAIL ® FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> SOD PROCESSING PLANT COMMISSARY ❑ ICE PLANT ® BAKERY <br /> ROAiDSIDE FOOD STAND 0 LIQUOR STORE 11 BAR 13 ITINERANT RESTAURANT <br /> CONFECTIONARY STORE 0 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 /> . HOUSING <br /> 13 HOTEUM TEUNo.of Units ❑ CERTIFICATE OF OCCUPANCY <br /> MOBILE HOME PARK/No.of Spaces' <br /> TER QUALITY 0 WATER SAMPLE(Bacterial) ❑ CHEMICAL <br /> PUBLIC WATER sSYSTEM 0 SURFACE WATER SUPPLY 13 WATER HAULER <br /> NOOF PUBLIC SERVED(Connections) <br /> 4. RECREATIONAL HEALTH 13 SWIMMING POOL ❑ SPA WADING POOL ❑ NATURAL BATHING PLACE <br /> VECTORS. CONTROL 13 POULTRY FARM/Maximum No.of Birds <br /> NEU un ays /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Wallef Supply Source Animal Waste Disposal Method <br /> 6. C)NSUTATioN FEE �' BUSINESS LICENSE <br /> 7. PLAN CHECKING FEE DANCE PERMIT <br /> . AL ESTATE <br /> REQUEST: Water Well Inspection C3 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 /> 0 hereby certify that Ia prep red tVanand that the work will be done in accordance with San Joaquin County <br /> ordinances,state s,and rul and rehe San Joaquin Local Health District. <br /> APPLICANT'S SIGNATU E _Title� t Vnc OC Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee ISDue: 13 LY 0 PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July I&Received By July 31 <br /> REMIT <br /> ILLING REMITTANCE' $ <br /> BASE EXPLANATION )PATEAMOUNT DUE CHECKED' <br /> DATE REMITTED <br /> .AMOUNT. <br /> FEE too aOD <br /> LESS <br /> PRORATION hle <br /> PLUS , <br /> PENALTY AAa <br /> OTHER <br /> OTHER <br /> i n <br /> ti <br /> v <br /> o <br /> 0 <br /> Received by Date Receipt Permit No Issuance DateMailed Delivered I <br /> Ix <br /> A (CANT—RET TO: ENVIRONME EALTH PERMIT/SERVICES 1801 E.HAZELTON A Bo:2009 STOCKTON,CA 95201 W <br /> j <br /> w - <br /> 1 <br />