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Applications WIII Be Processed When Submitted Property Completed. Be Sun 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 <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make -- <br /> BROKER ANO/OR Lid. No. -- <br /> LICENSE AND/OR FON ECTAIUSNMENTL Housm eg. <br /> R 1st. No_ <br /> REGISTRATION 394241 PU&LE.?N WATER SAMPLING - <br /> NUMBER __ REAL ESTATE INNECTOM Color <br /> POULTRY RANCHES AND KERNELS <br /> MISCELLANEOUS&ENTICES <br /> rApplication Date S-9-86 Business/Name To Appear On Permit Jerry Joy & Associates <br /> &Type Permit/Service Requested: —_— <br /> Applicant Name Valley Engine op A d ss Union . <br /> Business Telephone No. �1 Emergency Telephone No. <br /> Property Location/Address <br /> Property Owner Jay & Barbara Roek Address 5945 Cumberland Place <br /> LOperetor'sName Roger Martin Address 1040 N. Union St. <br /> T. 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 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 /> 2. 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 /> ❑ KENNEURunways /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 /> e. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> S. REAL 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 /> 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 rules and regulations of he San Joaquin Local Health District. <br /> APPLICANTS SIGNAT X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January T A Received By January St ❑ July 1 A ReCeivee Sy Juh]i <br /> BILLING REMITTANCE' E REMIT <br /> BASE EXPLANATION AMOUM WE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE 1 . O LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> OTHER <br /> s/1G � e <br /> Received DY Dery Ratelpl No. Perms No. Iaauence Deb tAalbO OeMvwed yvF <br /> APPLICANT—RETMaN C4 Ma To: REIYMONMaNTAL MDALTH PERMITIMAMCSS Nat L HAmTON AVL.P.O.Oft ANN STOCKTON.G fat M <br />