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Applications Will Be Processed When Submitted Properly Completed, Be Sure To Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR Make <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES -- <br /> BROKER AND/OR LIC. NO. -- <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> REGISTRATION TPUBLIC POOLSWATER SAMPLING Regist <br /> . No. <br /> f/ L ESTATE INSPECTIONS ColorNUMBER —1/H ^ J� POULEST RANCHEAND KENNELS r` <br /> o— /=�rp/ MISCELLANEOUS SERVICES t <br /> rApplication Date a/�njr Business/Name To Appear On Permd �� \l L'L <br /> eType Permit/Service:fiequested: <br /> APPligantNam e `l.l.i�t.�a.,�\Lt: Address.�L�T � <br /> o --`--11.. _ Business T lephone No.=_ =� �"tTnergency Telephone No. <br /> Property Location/Address 'a IA's h\- V c`=r_�C ✓r1 ev+� <br /> Property Owner S ih�`. = i:�tllt �\� ` C {=�'HoN�c3 <br /> L Operator's Name `` ` Address " <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 /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO.OF PUBLIC SERVED (Connections) <br /> 4. 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 /> S. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> T. 9L PUN CHECKING FEE P9 Uhr ADANCE PERMIT <br /> S. REAL ESTATE Q® rec Kr-r"J<5 <br /> REQUEST: Water Well Inspection 13 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, state laws,and rules and <br /> ddJJregulations of the San Joaquin Local Health District. ��77'�-- ,�11 � <br /> APPLICANTS SIGNATURE X 'K�/ Y /.LIt� Title 4T ."-�IA�vtGdOate <br /> FOR DEPARTMENT USE ONLY <br /> FN IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 S Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE' $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> OTHER <br /> �\�! <br /> Received by ,at <br /> ReeeiPl No, if Permit No. Issuance Date Mailed Delivered 0 <br /> Z <br /> APPLICAM—RETNaMJLA.COalESTO: ENV' VENTAL HEALTH PERMIT/SERVICES 1601 E.HAZE AVE..P.O.Boa 30M STOCKTON,CA 16301 W <br />