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f . <br /> ' 1 <br /> ` 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 F000 ESTABLISHMENTS.HOUSING Reglst. NO <br /> REGISTRATION PUBLIC POOLS.WATER SAMPLING <br /> NUMBER REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> /�1 Q MISCELLANEOUS SERVICES <br /> rApplication Date �` Business/Name To App r On Permit — F_i �N Fit LK ARS L.L. <br /> wType Permit/Service R uested: —ApplicantNameC �-� .. fddreas / -� - <br /> Business Telep o e NO. ` 92 -5/a �..1 Emergency Telephone No. <br /> Property Location/Address��N �r I✓y�r -- <br /> Property Owner C C L S H` - \ S, Address _3l t Y'r H-1 �\ <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 /> ❑ HOTEVMOTEL/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 /> e. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> ❑ KENNEL/Runwsys /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> W ter Supply Source Animal Waste Disposal Method <br /> CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> S. REAL ESTATE <br /> REQUESTS Water Well Inspection 1:1 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 q spared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,stet <br /> Tlaws, nd rul and regule ns oft San Joaquin Local H/en✓al_th District. <br /> APPLICANT'! SIGNATUR -- _ Title - ,A Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 A Received By July 31 <br /> REMIT <br /> S <br /> BASE EXPLANATION BILLING REMITTANCEDATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> Q <br /> OTHER <br /> Received by Date Reoeipt No. Permit No. Issuance Date Mailed Delivered t <br /> y <br /> APPLICANT—PETWMJMICOME[TO: ENVIaptlYENTAL MEALTN PERMIT/BERVICEB 1te1 E.HAZELTON AVE..P.O.Boa 20111119TOCKTON,CA tetel <br />