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pow <br /> Appllaatlon•Will Ba Pr ssAd Whan Subnitlad Properly Completed. Ba Sure To a19.Th.APPllatlon. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENOINEEwa AND/OR APPLICATION IF VEHICLE INVOLVED.GIVE <br /> APPLICANT'e AND/oR Make -- <br /> coHTRACTORA (X! ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> Lid. No. -- <br /> BROKER ANO/Oil <br /> LICENSE AND/OR roCO ESTABLISHM[1Rf.NBUalaf Regist. No REGISTRATION PUBLIC POOLS.WATER SAMPLING <br /> NUMBER REAL ESTATE IRSPECnO" Coior <br /> MUST RANCHES AND KENNELS <br /> �/ MISCELLANEOUSSERVICESSERVICESSERVICES <br /> rApplication Date (P rOBusines�Name To Appear On Permit <br /> tt.Type Permil/Senice Requested: <br /> Applicant Name Address \ Z <br /> _ Business Teleph ne No. �'C:!Qyp© Emergency Telepho a No. .1�E-'�79d <br /> Property Location/Ad ass ` <br /> Property Ownel /[A!QS(�' r TAfOFrigA Address y Aff <br /> I Operator's Name 5LW Address (Ce 17 <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage RestauranL 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 HARVFSTING/No.of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> i HOUSING <br /> ❑ HOTEL/MOTEL/No.of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces <br /> 1 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 /> LCONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. PLAN CHECKING FEE ❑ DANCE PERMIT <br /> L REAL ESTATE <br /> REQUEST: Water Well Inspection❑ Sample Tittle Company <br /> Sewage System Inspection ❑ Address Tale.No. <br /> Escrow No. <br /> Seller Seller Address I <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 rubs and regulations Of the San Joaquin Local Health District G <br /> APPLICANTS SIGNATURE X,� nog e Q yTttb Data 1, <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY 0 M UNIT ❑ PER SITE ❑ EACH ❑ J..ry 1 A R—u By Jenwry 31 ❑ Jury 1 A Recensd BY J lv 71 <br /> BILLING REMITTANCE f REMIT <br /> BASE EXPLANATIONBILLING <br /> DATE REMITTED AMOUNT DUE CHECKED <br /> D <br /> -y— / AMOIJrrT <br /> FEE — 5/ ` ,�p {� <br /> LESS <br /> PROIIATION ! t/ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7 <br /> ReCwTw]by pie F e ,W No. +d luuero Deo flexed Delr.ered i <br /> ARLICANT-IIEnMNJLL1fQaEA�TR EMYIaOMYENTLL N[ALTH PENYIT/1ENYICEt LABS G NAI(LTON AY[,P.O.aaISOs BTOCNTpIL U MA1 <br />