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Y <br /> Applications WIII Be Proeieeed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR <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,NOUSINS Li C. NO. <br /> REGISTRATION �p PUBLIC POOLE WATER SAMPUNS Reglst. No. _ <br /> NUMBER--(l W VC.4z REAL ESTATE INSPECTIONS <br /> Color— <br /> POULTRY NANCHES AND KENNELS -- <br /> Application Date /_�p�$� ToAppear <br /> O Permit � co <br /> Business/Name To Appear MISCELLANEOUS Permit _ <br /> iType Permit/Service,B�aoue�sted: 6'/4 r- DIp�,P L- STD 12.y5 e-Applicant <br /> --- <br /> APDlicant Name .? (/VY tArV ICi I1 �"1Z Address- t O 1cf1 W, RZ _- <br /> _ Business Telephony No. `�L C� -Co7 Cs C. Emergency Telephone No. 9, f/6 3 <br /> Property Location/,Apdr ss /O ate/ W. lLRl9rrlpw G t; $�(,C{'�y` -- S fY To 2. <br /> dPropertyOwner .16//L-BCW_ fy Co /nt 6 <br /> Address <br /> ¢20 <br /> L Operator's Name . /yY.y" TiZ Address_ /a- 760 41rk/n d"L, led, <br /> Go <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 • ,f <br /> ALL APPLICANTS: Total Employees Including Operators ] r 'i�//V i1 ���,,..// <br /> 2. HOUSING J�,J <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 /> B. 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 /> B. WCONSULTATION FEE .S O(7 ❑ BUSINESS LICENSE <br /> 7. q PLAN CHECKING FEE .. S•VO ❑ DANCE PERMIT <br /> S. REAL ESTATE <br /> REQUEST: Water Well Inepectlon❑ 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,stale laws, d rules and regulations Of the San Joaquin Local Health District. <br /> APPLICANTS SIGNATURE X Title'-/Y'-4:f7/2, Date /G <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 8 Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE' $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE <br /> /7,/1 L'n ll i, AMOUNT <br /> LESS <br /> PRORATION <br /> PLUG <br /> PENALTY <br /> OTHER L� -- <br /> OTHER p <br /> L' IC - <br /> Racanae <br /> —by Dery R pt No, Pwmlt No. beuence Data Mailed Delivered <br /> AFPLICAIrt-INti'WIALL,pORMa T@ BMVMOYYp1$Al NeALTN PERYRMERVICG 1M/E.HAZELTON AVE.,P.O.aoa 2M STOCKTON,CA all <br /> w <br />