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Applications WIII Be Proce, d When Submitted Properly Completed. Be Sure— Sign The Application. <br /> SATS JOAQUIN LOCAL HEALTH DISTRXT 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 L.C. NO. <br /> LICENSE AND/OR F000 ESTABLISHMENTS,SOUSING <br /> REGISTRATION PUBLIC POOLS.WATER SAMPLING Regist. NO. <br /> NUMBER REAL ESTATE INSPECTIONS n A Color <br /> POULTRY NEXUSES AND KENX S <br /> _ MISCELLANEOUSSERVICES <br /> rApplication Date B ine Name To Apearear On Permit <br /> rType Permit/Servi e R u d <br /> Aicant N e Address O H _ <br /> Busi ess Telephone No. Emergency Telephone No. <br /> (Property Location/Address aLAI <br /> I --- <br /> (Property Owner v Address 6� <br /> L40perator's Name_ <ns Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Seating Capacity <br /> d 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 /> ❑ HOTEL/MOTEL/No.of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces <br /> 2. 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 /> 5. 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 /> W ter upply Source e2 _ Animal Waste Disposal Method <br /> S. CONSULTATION FEE " 13 BUSINESS LICENSE <br /> 7. PLAN CHECKING FEE\L ^ ❑ 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 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANTS SIGNATURE X , Ny,:& Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 3 Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE' S <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE V 0AU5 .O O <br /> LESS <br /> PRORATION aY <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Oata Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETLRNJLLCOEIES.TO. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAIELTON AVE.,P.O.Boa 2009 STOCKTON.CA SS201 <br />