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c f <br />0 <br />t Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />ENGINEER'S AND/OR <br />APPLICANT'S AND/OR <br />CONTRACTOR Al <br />BROKER Al <br />LICENSE AND/DR <br />REGISTRATION <br />NUMBER <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />FOOD ESTABLISHMENTS, HOUSING <br />PUBLIC POOLS. WATER SAMPLING <br />REAL ESTATE INSPECTIONS <br />POULTRY RANCHES AND KENNELS <br />ES <br />GENERAL <br />IF VEHICLE INVOLVED, GIVE <br />Make -- <br />Lic. No. <br />Regist. No. _--_ <br />Color <br />_ MISCELLANEOUS SERYIC j <br />[Application Date fit%'- 1 Busi <br />ness <br />/Name To Appear On Perl —Llk <br />s,Type Permit/Service Requested:�t <br /><APPlicanlName�{7 Address CrG �a.95 �I �,� <br />qtl d Business Telephone �No.LLI_ _ Emergency Telephone No. <br />iProperty Location/Addrr�e""ss z,3t.e <br />11 Property Owner l�i11'fE � ��} _ _ Address �f 7 5 �c�wl� Sn,c�v rLC+cir LA Z4U s4t�ii� <br />!/Oil I "� <br />L Operator's Name �'Fdlr � bG�cr4 _ _. Address r`ut. <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 ❑ LIOUOR 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 f _ <br />2. HOUSING <br />❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br />❑ MOBILE HOME PARK/No. of Spaces[,% f {� <br />3. WATER QUALITY 11 WATER SAMPLE (Bacterial) ❑ CHEMICAL I'�/r`iji � AfY <br />IJ PUBLIC WATER SYSTEM 11 SURFACE WATER SUPPLY 11 WATER HAULER lf' <br />NO. OF PUBLIC SERVED (Connections) <br />4. 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 />SewagejDisposal Method <br />So�"aste Disposal Method <br />Water Supply Source Animal Waste Disposal Method <br />B. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br />7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT - <br />&. 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 _. a <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 regulations of the San Joaquin Local Health District. <br />APPLICANT'S SIGNATURE X <br />Title �wi�ISctlny%CNr TN Date /0'1 ^6'Sr <br />�_/ V FOR DEPARTMENT USE ONLY <br />.......w, v n oco —I, FI Drw ciTc n EACH Ll .lanuary 1 & Received By January 31 ❑ July 1 S Received By July 31 <br />Aeceived by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br />— APPLICANT—RETURN ALL CdRLES,TO: ENVIBONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE., P,O. Box 21109 STOCKTON. CA 95201 — <br />REMIT <br />BASE <br />BILLING REMITTANCE <br />EXPLANATION <br />$ <br />AMOUNT DUE <br />CHECKED <br />DATE DATE <br />REMITTED <br />AMOUNT <br />FEE <br />��- <br />J n <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />Aeceived by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br />— APPLICANT—RETURN ALL CdRLES,TO: ENVIBONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE., P,O. Box 21109 STOCKTON. CA 95201 — <br />