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Applications Will Be Processed When Submitted Property Completed. Be Sure'ro Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S ANO/OR APPLICATION IF VEHICLE INVOLVED, GIVE <br /> APPLICANTS ANO/OR Make <br /> WONTRACTOR ANO/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> _,BROKER AND/OR Lid. NO. <br /> LICENSE ANO/OR FOOD ESTARUSRMENTS,HOUSING <br /> REGISTRATION G'//G/.•-s / "BLIC POOL IL WATER SRMFIING RegiSt. NO. <br /> NUMBER / l V HEAL ESTATE IRa/ECTIONS Color <br /> MULTRY RANCHES AND KERNELS <br /> / 11HUELLANEDUS SERVICES <br /> (Application Date r � Busmess/Name To Appear On Permit <br /> .Type Permit/Service Requested: 7,—I,� "L fl/v L � <br /> i <br /> Applicant Name �i//,.a�,.r �moi+� f c If Aotlress /` / F � il4• /c <br /> _ Business Telephone NGL ' - 7 - Map one o <br /> g Property Location/Address L/ '/'.>•r/ !✓'E' '� •" �"� / "' <br /> dProperty Owner v Address /O �L 6✓rJ���re 7r S 7�.G%' <br /> L Operator's Name Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant Maximum Seating Capacity <br /> ❑ RESTAURANT D 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 Feld 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 ❑ 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 /> Wit Supply Source _ Animal Waste Disposal Method <br /> CONSULTATION FE ❑ BUSINESS LICENSE <br /> T. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> & 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 this application and that the work will be done in accordance with San Joaquin County <br /> ordinances. state laws._Sgd rules and regulationf of the San Joaquin Local Health District <br /> APPLICANTS SIGNATURE 4- .�+--plc-G Title /r, Date <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January]t ❑ July 1 a Receiree By July 31 <br /> REMIT <br /> BASE EXPLANATION BIDLLAh REMIDIT� A AMOUNT OUE CHECKED <br /> L REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> —/Z-/`-+/JJ(([[�y' <br /> l <br /> Ketenes <br /> by DVN Re:eiq No. Parmlt NR. 1.0. Maines OMiroieG t <br /> APPlICA11T-RFrIIYI c•' CrOaMiTC. ENVUROtlYBI HGETN PERMm/sF.RVICFR tem E NII2RLTON AVE,P.O.sea IDee STOCxTpI,U exalt w <br />