Laserfiche WebLink
I 1 j 6 s <br /> Applications Will Be Pry'cessed When Submitted Properly Completed. Be Sure Yo Sign The Application. <br /> SAN JOACIUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR Make <br /> ,QONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES -- <br /> -BROKERAND/OR Lic. No. <br /> LICENSE AND/OR F000 ESTABLISHMENTS.HOUSING Re ISI. NO. <br /> REGISTRATION/�A ) PUBLIC POOLS.WATER SAMPLING g <br /> NUMBER +--� 7 _ _ REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> �- '- 1,.J(' it <br /> MISCELLANEOUS SERVICES <br /> rApplication Date 1 - 1 - Business/Name To Appear On Perm2GCL Gl <br /> Type Permit/Se rvice 77 Requested: 1„ TAj VL- _-f=eiwl. <br /> Applicant Name 1'�u c�S..,..\ ��E�,L-..Qs�~. Address SIGs e" 2 _ <br /> u S d-o ,-k(.1,I (L _ Business Telephone No. 7. J S ��j'J ETergency Telephone No. <br /> Property Location/Address a.�_h1 1�rr,�2»+k,_�Qc� L o Ckk <br /> Property Owner .�'' � 5..�{cT �_M . �.t� 14 Address `a.007 It 4R_- Ili 4=...) <br /> L Operator's Name Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> q 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 /> 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 /> S. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. 0 PLAN CHECKING FEE V&S-1 ❑ DANCE PERMIT <br /> S. REAL ESTATE <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 gulati sof San Joaquin Local Healltthh District. f3� <br /> APPLICANTS SIGNATURE X�� Title /'�nrS Dale 7 �J v"U <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑July I A Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE a <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 1 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> Y <br /> OTHER <br /> �3 CD <br /> Received by Date <br /> Receipt No. Pormit No. lasuence Dab Mailed Delivered Z <br /> AMLICANT—RETMaNIL CONAE&TO: E iNMENTAL HEALTH PERMIT/SERVICES 1001 E.HA SN AVE.,P.O.ba 1000 STOCKTON,CA NMI N <br />