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L' <br /> Applications WIII Se Pro. .sod When SubmI11"Property Completed.Be s AM The AppMeMlon. <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION <br /> APPLICANT'S AND/OR IF VEHICLE INVOLVED,GIVE <br /> CONTRACTOR ANO/ORMake -- <br /> BROKER ANO/OR C ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> LICENSE ANO/OR Sam& 4n FON ESTA11I MMEMTT,0191111111111116Lid.NO. <br /> REGISTRATION MLIG MOLS,WATER SAMPIINO Regist.No. <br /> NUMBER PF 1400t� A. EIEAL ESTATE INSFUTNNS Color <br /> l- ms Wr T� MMII EELLAMEWfiQONIEENiE'IME`S <br /> rApplication DateBusiness/Na To A or On Permit ` ��SI;I <br /> Re <br /> Type Permit/Servics q ested: j <br /> Applicant Name r Cars Add r ss <br /> _ Business elephone No. — Emergency Telephone No. <br /> Property Location/Address /1 <br /> Property Owner_Tc LC.f1ex+ Wiz. Address <br /> i Operator's Name Sdt a -- no _ Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Seating Capacity <br /> d 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 ❑ VENDI \11,rU <br /> 13 FOOD CROP HARVESTING/No.of Field Employees � <br /> ALL APPLICANTS: Total Employees Including Operators v <br /> 2 HOUSING ` MAS �ga9 <br /> ❑ HOTEVMOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY WcpLIW <br /> ❑ MOBILE HOME PARK/No.of Spaces ,Imov'L <br /> S. WATER QUALITY 13 WATER SAMPLE (Bacterial) 13 CHEMICAL EN�PE MIT SERVICE$ <br /> O PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO.OF PUBLIC SERVED(Connections) <br /> i. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> L VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds <br /> 13 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 /> i. KCONSULTATION FEE ❑ BUSINESS LICENSE <br /> T. ❑ PLAN CHECKING FEE i-jillit petAa ❑ DANCE PERMIT <br /> S. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tele.No. <br /> Escrow No. <br /> Seller Seiler Address <br /> Telephone No. Seller Agent Name <br /> Service Request For Date <br /> I hereby certify that 1 ve prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state la a d and regulations of the San Joaquin Local Health District. <br /> APPLICANTS SIGNATURE X Title �G$r 0/ Date O �G— <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 i Received By January 91 ❑July 1 i Received By July 31 <br /> BILLING REMITTANCE' Z REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> OTHER n <br /> 0 <br /> 0 <br /> Received by Date Receipt No Permit No Issuance Date Mailed Delivered X <br /> APPLICANT—RETURN ALL GOP"TO.' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1001 E.HAZELTON AVE.,P.O.Bot.2001 STOCKTON.CA 95201 W <br />