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04*AEEfts ANQIOR <br />APPLICANT'{ AND/OR <br />CONTRACTOR AND/yi <br />eRO1rOt ANS <br />rApplieation Date <br />.Type Permit/Sen <br />Applicant Name, <br />Property D <br />L Operator's <br />Al <br />Applications WIN B%SYbn1111ed Properly Completed. Be Sif v-10 Sign The Application. <br />SAN JOA UIN LOCAL HEALTH DISTRICT GENERAL <br />APPLICATION <br />TAL HEALTH PERMIT/SERVICES <br />FEES gnAN OMMMM NVJSM <br />FUNIC IML{, NATES EANMIM <br />NEAT MAU MINCTIEM <br />MULTET MINIMUS AM KFMK a <br />EnC p O SERVICES <br />To Appear On Permit /A -/_ ,z <br />IF VEHICLE INVOLVED, GIVE <br />Make <br />Lid. No. <br />Regist. I <br />Color _ <br />Business Telephdn6We. = Emergency <br />Z m e" :.✓./ 1 rz , A <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 HARVESTINGAIO. of Field Employees _ <br />ALL APPLICANTS: Total Employees Including Operators <br />2 HOUSING <br />❑ HOTEL/MOTEUNO. of Units ❑ CERTIFICATE OF OCCUPANCY <br />❑ MOBILE HOME PARK/No. of Spam <br />S. 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 West* DIsoOlal Method <br />Water Supply Source <br />IL A CONSULTATION FEE - i 13- <br />7. <br />7. ❑ PLAN CHECKING FEE ❑ <br />S. REAL ESTATE <br />REQUEST: Water Well Inspactkm[3 Sample❑ Title Company <br />Sewage System inspection ❑ Address Tele. No. <br />No. of Confining Caen <br />Animal Waste Disposal Method <br />BUSINESS LICENSE <br />DANCE PERMIT <br />Escrow No. <br />Seller <br />Seller Address <br />Telephone No. Seller Agent Name <br />Service Request For Date <br />I hemhy 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 rubs and r, puletions of the Sen Joaquin Local Health District. / <br />APPLICANTS SIGNATUR Tit1eL Date Lo — j(- 9z <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE... ❑ FACH ' ❑ Jalnlery 1 a P.wmd By JMluery dl ❑ July 1 L RepiVW By July 11 <br />REMIT <br />BASE <br />EXPLANATION <br />BILLING <br />REMITTANCE <br />S <br />AMOUNT DUE <br />CHECKED <br />DATE <br />DATE <br />RE((MM'ITTED <br />AMOUNT <br />vo <br />ffO <br />/l3%(]d <br />FEE <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />Nog3to <br />R[cww10 by DAN R "I NP. P[Im,l No <br />— AIPLKANT—RETMEKJ1lLOOtlE►TO: [11YalONYENTAI M[ALTM P[AYITIe[AVIC[f <br />IMuu Deb McIHd Dwiwnd <br />1Wl LH ELTON AV[.►.O. ao. 2010 eToCaTON, CA taWl <br />