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Applications Will Be Procr +d When Submitted Properly Completed. Be Sur, Sign The Application. <br /> ENGINEER'S AND/OR SA ; JOAQUIN LOCAL HEALTH DISThI(,T GENERAL <br /> APPLICANT'S AND/OR APPLICATION IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br /> BROKER AND/OR -- <br /> LICENSE AND/OR FOOD ESTABLISHMENTS.HOUSING Lic. NO. <br /> REGISTRATION PUBLIC POOLS.WATER SAMPLING Regist. No. <br /> NUMBER REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES 1 <br /> FApplication Date Busines /Name To Appear On Permit by)-Ie4 QnC1Z%rh rh'ar) <br /> Type PermiVServIce equested fG10L)f) ►P� S'faI'aC� <br /> Applicant Namti n\At?:, h ynp,{�/Spm XT <br /> )C t C Address k Lq6 1 ICA 'Z, <br /> ` <br /> Business Telephone NO.Q� Z Emergency Telephone No. AA <br /> Property Location/Atldr@ss'�ol a {b()('-�� �'t' Q�O/1 2 p� <br /> a Property Owner �tl�+r"1'-4 �.I YTIMC7.I'wxt,() a <br /> s Address da'a'��lX'�'1 A R NIQOn t l.Yl <br /> L Operator's Name" Address Or �r <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 /> 2. HOUSING <br /> ❑ HOTEUMOTEUNo. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces <br /> 0. 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 /> 8. CONSULTATION FEE r ❑ BUSINESS LICENSE <br /> 7. PLAN CHECKING FEE :ZI ,off ❑ 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 Courtly <br /> ordinances, state laws,and rules an regulations of the San Joaquin Local Health Dist ict. - <br /> APPLICANT'S SIGNATURE TitleIWW_SDate, <br /> FOR DEPARTMENT USE ONLY <br /> Fee is DIN: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE S REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE r O(7 0(7 <br /> LESS y� Fewl <br /> PRORATION 25s� <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURNILLCORa:S TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2005 STOCKTON,CA 53201 <br />