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Applications WIII Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL �l <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR Make -- <br /> CONTRACTORAND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> BROKER AND/OR Lic. NO. <br /> LICENSE ANO/OR FOOD ESTABLISHMENTS,HOUSING RegiSt. No. <br /> REGISTRATION PUBLIC POOLS,WATER SAMPLING - <br /> NUMBER REALEST ATE INSPECTIONS Color <br /> POULTRYRANCHES CMO KENNELS — _-_— -- <br /> L <br /> MISCELLANEOUS SERVICES <br /> [Application Date 44A.-2—� 101 Busine /Name To Appear On <br /> Permit !-- <br /> »Type Permit/Service R uye-BE I ErA cii-jQ <br /> Applicant Name 1 `� t Address h� mL�2r <br /> Z� _ Business Tele hone o. 3 EmergencX Telephone No. <br /> Property Location/Address 5kV5b V 5 /'�'C� <br /> Property Owner J._�.,,.1 ��L Address <br /> L Operator's Name�OL.1�LOA)CII T. I'll E4�0 CiQ..r-- 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 APPLICANTS: Total Employees Including Operators <br /> Z. 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 /> 1 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 /> `� CONSULTATION FEE s•DD ❑ BUSINESS LICENSE - <br /> 7. ❑ PLAN CHECKING FEE ❑ 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 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,a les and regulations of the San Joaquin Local Health District. <br /> Vv <br /> APPLICANT'S SIGNATURE X Title M S • Date 2 w <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 d Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS a <br /> PENALTY <br /> OTHER - <br /> OTHER <br /> Received M Dale Hecei Pl No. Permd No. lesuanee Date Mailed Delivered Z <br /> APPLICANT-RETMaNJ Clla TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 11101 E.HAZELTON AVE..P.O.Boa a1C9 STOCKTON,CA 95401 M <br />