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r <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S ANO/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR Make <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES --- <br /> BROKER AMD/OR Lic. No. —--- <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,HOUSING Regist. No. <br /> REGISTRATION PUBLIC POOLS,WATER SAMPLING "— <br /> NUMBER REAL ESTATE NISPECTIONS Color_ ----_ <br /> POULTRY RANCHES AND KENNELS <br /> T MISCELLANEOUS SERVICES ,J�y /U t� <br /> FApplication Date Nov - Z�,rl ��_. Business/Name To Appear On Permit KEY t\ U 1 ----- <br /> Type Pertnit/Serviice Requested: --.___— -- ----- - -- -- <br /> APDIiCan>I Name JZ. 1..nnL,� <br /> ++ EVC=1Y` 5 CO Address <br /> L. It �_ i j P Business Telephone No.*5_=.S.__Cj__�a.9�1� Emergency Telephone No. — <br /> Property Location/Address !-- —fq <br /> —t---- <br /> Owner Z � U <br /> Property <br /> 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 APKICANTS: 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 C <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 /> S. VECTOR CONTROL ❑ 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 /> 6. B-CONSULTATION FEE 3!6" ❑ BUSINESS LICENSE <br /> T. tk PLAN CHECKING FEE �sr a� ❑ DANCE PERMIT <br /> 6. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample 11 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 t h e prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state I a rulej <br /> re alio of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE �s Title 0 - Date <br /> 1 FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 b Received By January 31 ❑ July 1 6 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE' $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEB Q-Cr 0 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER ,, <br /> Y <br /> m <br /> OTHER <br /> I n <br /> 0 <br /> N <br /> Received by Date R o Permit No. Issuance Mailed Delivered X <br /> APPLICANT—RETU&KALL.COS"TO: ENVIRO AL HEALTH PERMIT/SERVICES 1601 E.HAZELT�..P.O.Bo=NO STOCKTON.CA 95201 W <br /> I - - <br />