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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR Make----- - - - <br /> CONTRACTORAND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> LIC. NO. <br /> BROKER AND/OR — -- <br /> LICENSE AND/OR F000 ESTABLISHMENTS,HOUSING Regist. NO. - - <br /> REGISTRATION PUBLIC POOLS WATER SAMPLING <br /> NUMBER REAL ESTATE INSPECTIONS Color - <br /> POULTRY RANCHES AND KENNELS <br /> q 'aa MISCELLANEOUS SERVICES cI <br /> P <br /> rApplication Date -Z`�a� u ine /N e D App ar ermit,___._ U roll V. S A r <br /> Type PermiVService Requested:_ d\."+ <br /> Applicant Name WAYNLT Q. SNt,T'a+ Adores Z Annal6e -cLNEE SVl�lr ZOQ_ <br /> u (X^ <br /> �.xvi,W%.Z4. Q451&5 _Business Telephone No CyIS)838`SZSI Emer ency Telephone No. 9r$)ZZ2'8(.ZN <br /> Property Location/Address Worst Q 1�1 TVa ' A . J <br /> Property Owner OMQ✓ ii/:�CMRh Address 0. O N Trw� Ca.. 537 <br /> s c-1 c „ yt ;� �SQd 7Azlni <br /> L Operator's Name JArn1tS MEGCrU N Address 5 37(0 <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 13 LIQUOR STORE ❑ BAR 13 ITINERANT RESTAURANT <br /> .:ONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/No.of ❑ MOBILE FOOD PREP.UNIT ❑ VENDING VEHICLE <br /> ❑PFOOD CROP HARVESTING/No.of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> Z. HOUSING <br /> ❑ HOTEL/MOTEVNO.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 /> N0, 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 C nfining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> aCONSULTATION FE ❑ BUSINESS LICENSE <br /> 7. PLAN CHECKING FEE _ ❑ DANCE PERMIT <br /> a. 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,and rulesandregulations of the San Joaquin Local Health District. c- , y '/ <br /> APPLICANT'S SIGNATU <br /> / ` Title r-10 ['n Date��L - <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is DW: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 S Receiv VCHE <br /> By July 31 <br /> MIT <br /> BASE EXPLANATION BILLING REMITTANCE S IT <br /> AMOUNT DU <br /> DATE DATE REMITTED <br /> a <br /> FEE LESS ����`` ` <br /> PRORATION JJ SO 1 O� <br /> PLUS <br /> PENALTY I <br /> OTHER ( C 3 - 3 09 <br /> OTHER _NIY� d <br /> — <br /> ggeived DY Date ceipl NO. Permit N0ce. IssuerDate Mailed Del--.led <br /> .�APPUCANT-RETMRMALL-CCaM&TO. Er NMENTAL HEALTH PERMIT/SERVICES 1601 E.HA" 9N AVE..P.O.Bas 200111 STOCKTON.CA 95201 <br />