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Applications Will rocs eeed When Submitted Properly Completed. Bf fro Sign The Application. <br />NEW ...i <br />SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br />ENGINEER'S AND/OR <br />APPLICANT'S AND/OR <br />CONTRACTOR AND/OR <br />BROKER AND/OR <br />LICENSE AND/OR <br />REGISTRATION <br />NUMBER a3— <br />Type <br />1 <br />rTyplic ermi Date <br />ttt.Type PermiVServic Re ,sled: r <br />Applicant Name t <br />Property LocationT/Address /dlx� <br />aa Property Owner 1>OC IZA-YMoe+ <br />L Operators Name <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />FOOD ERTABUSNMENT; MOUSING <br />PUBLIC POOLS, WATER SAMPUNG <br />REAL ESTATE INSPECTION$ <br />POULTRY RANCNES AND KENNEW <br />MISCELLANEOUS SERVICES <br />To Appear On Permit,_ <br />IF VEHICLE INVOLVED, GIVE <br />Make <br />Lid. No. — <br />Regist. No. <br />Color <br />No. `9 Y9. 2 /{Z- Emergency Telephone No. <br />Address <br />Address <br />1. FOOD ESTABLISHMENTS <br />Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br />❑ RESTAURANT ❑ FOOD MARKET RETAIL <br />❑ FOOD MARKET WHOLESALE <br />❑ MEAT MARKET <br />❑ FOOD PROCESSING PLANT <br />❑ COMMISSARY <br />❑ ICE PLANT <br />❑ BAKERY <br />❑ ROADSIDE FOOD STAND <br />❑ LIQUOR STORE <br />❑ BAR <br />❑ ITINERANT RESTAURANT <br />❑ CONFECTIONARY STORE <br />❑ FOOD SALVAGER <br />❑ FOOD DEMONSTRATION <br />❑ FOOD VENDOR <br />❑ VENDING MACHINES/No. of <br />❑ MOBILE FOOD PREP. UNIT <br />❑ VENDING VEHICLE <br />❑ FOOD CROP HARVESTING/No. of Field Employees _ <br />ALL APPLICANTS: Total Employees Including Operators <br />2 HOUSING <br />❑ HOTEUMOTEUNo. 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. <br />Sewage Disposal Method <br />Solid Waste Disposal Method <br />Water Supply Source <br />D. ❑ CONSULTATION FEE ❑ <br />7. PLAN CHECKING FEE ❑ <br />D. REAL ESTATE <br />REQUEST: Water Well Inspection 13 Semple❑ <br />Sewage System Inspection ❑ <br />Escrow No. <br />Seller <br />Telephone No. <br />Service Request For Date <br />No. of Confining Cages <br />Animal Waste Disposal Method <br />BUSINESS LICENSE <br />DANCE PERMIT <br />Title Company <br />Address <br />Seller Address <br />Seller Agent Name <br />Tele. No. <br />I hereby certify that I hav Bred this applicatio and that the work will be done in accordance with San Joaquin County <br />ordinances, state laws, rut and r1aayons n Joaquin Local Health District. <br />APPLICANTS SIGNATURE X %C - c / Title Date <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Revived By January 31 ❑ July 1 S Received By Jury 31 <br />REMIT <br />BASE <br />EXPLANATION BILLING <br />REMITTANCE'DATE <br />S <br />AMOUNT DUE <br />CHECKED <br />DATE <br />REMITTED <br />AMOUNT <br />FEELESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHeR <br />l <br />Received by Dale Receipt No, Permit No. Issuance Dale Malted DeIrmnel <br />_ ........._ern.e., .,, enema m. cw,enwcrru ucu ru acemrracevraca rms c uam mu avc en e.... vv . a w]e1 <br />