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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENEPAL <br /> ENGINEER'S AND/OR <br /> APPLICANTS AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br /> BROKER AND/OR Lic. No. <br /> LICENSE AND/OR F000 ESTABLISHMENTS,HOUSING Regist. NO. <br /> REGISTRATION PUBLIC POOLS WATER SAMPLING 9 — <br /> NUMBER REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> [Application Date zo-a 9-�'s Bu in 5s/Name To Appear On Permit <br /> wType Permit/Service Requesteo[ - v r _ <br /> Alpypliccanit,Nammg�411A] PlIaG /b ul /fi C3 Atltlress P` V (/ <br /> Business Telephone No.?�y 7 as 0 Emergency Telephone No. <br /> K Property Location/Address , <br /> d Property Owner U' ,GNf A1/— gddress <br /> L Operator's Name M /!O &el .niln 04 LI61Z Addre2.1ss <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Seating CapacitAo y)f!tQ�Q 6 <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 /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) <br /> a. 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 /> 6. M(CONSULTATION FEE SS, OQ ❑ 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 1 have prepared this apj; cation and that the work will be done in accordance with San Joaquin County <br /> ordinances,state law nd rules and regu fo C/ -. <br /> Ftbf the San Jo quin Local Health District. <br /> 1 P X <br /> APPLICANT'S SIGNATURE ". _ Title Date �� <br /> FCIR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 A Received By July 31 <br /> BILLING REMITTANCE S REMIT <br /> BASE EXPLANATION DATE DATEREMITTED AMOUNT DUE CHECKED <br /> C ! l AMOUNT <br /> PEE 35 00 <br /> LESS <br /> PRORATION <br /> PLUS �� <br /> PENALTY <br /> OTHER <br /> OTHER <br /> to <br /> eceived by Date Receipt No. Permit Na Issuance Dale Mailed Delivered <br /> Z <br /> APPLICANT—RETItaNALLfLPJES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.NA2ELTON AVE.,P.O.Boa 2002 aTOCKTON,CA 26201 W <br />