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ENGINEER'S AND/OR <br />APPLICANT'S AND/OR <br />CONTRACTOR AND/OR <br />BROKER AND/OR <br />LICENSE AND/OR <br />REGISTRATION <br />NUMBER <br />Applications Will FlAossed When Submitted Properly Completed. Be Su. Sign The Application. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br />APPLICATION IF VEHICLE INVOLVED, GIVE <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br />'Application Date -�O- / - Ekr . Rusin Ss/N <br />Flype Permit/Service Requested: -- --e-zr� <br />APPlicant Name CTQ4y }\ (;ASS Lik'kT <br />(9S2utl _ Business <br />Property Location/Address <br />j Property OwnerTA Irr- ei i <br />L Operator's Name Si'EJr_ ew-kii <br />FOOD ESTABLISHMENTS, HOUSING <br />PUBLIC POOLS WATER SAMPLING <br />REAL ESTATE INSPECTIONS <br />POULTRY RANCHES AND KENNELS <br />MISCELLANEOUS SERVICES <br />To Appear On PermtTL <br />Address <br />Address <br />Address <br />Lic. No. _ <br />Regist. No. <br />Color <br />Emergency Telephone No. <br />1. FOOD ESTABLISHMENTS - Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br />❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE 13 MEAT MARKET <br />11FOOD PRO ESSING PLANT <br />❑ COMMISSARY <br />❑ ICE PLANT <br />❑ BAKERY <br />❑ ROADSIDE FO TAND <br />❑ LIQUOR STORE <br />❑ BAR <br />❑ ITINERANT fiESTAURANT <br />❑ CONFECTIONARY ST <br />❑ FOOD SALVAGER <br />❑ FOOD DEMONSTRATION <br />--O"EOOD VENDOR <br />❑ VENDING MACHINES/No. of <br />❑ MOBILE FOOD PREP UNIT <br />❑ VENDING VEHICLE <br />❑ FOOD CROP HARVESTING/No. of FieldEly <br />ALL APPLICANTS: Total Employees Including <br />2. HOUSING <br />❑ HOTEVMOTEVNo. of Units <br />❑ MOBILE HOME PARK/No. of Spaces �� <br />3. WATER QUALITY 11 WATER S LAMP E (Bacterial) ❑ CHI <br />❑ PUBLIC WATER SYSTEM Q SURFACE WATER SUPPLY <br />NO. OF PUBLIC SERVED (Confiections) <br />A. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ 1 <br />5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birc <br />❑ KENNEV nways /Animal Population No. <br />Sewage spossl Method <br />Sol' aste Disposal Method <br />Water Supply Source <br />S. ❑ CONSULTATION FEE r ❑ <br />T. ❑ PLAN CHECKING FEE ❑ <br />S. REAL ESTATE <br />❑ CERTIFICATE OF OCCUP/lANNCYY�n <br />ER HAULER <br />1 i <br />............omo wMwm moon <br />BUSINESS LICENSE <br />DANCE PERMIT_ <br />REQUEST: Water Well Inspection El Sample❑ Title Company <br />Sewage System Inspection ❑ Address <br />Escrow No. <br />Seller <br />Telephone No. <br />Service Request For Date <br />Seller Address <br />Seller Agent Name __. <br />r_ <br />Tele. No. <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 <br />Title SuPlrZIN*CAIJff'l Date 262 "/ -&j <br />FOR DEPARTMENT USE ONLY _ <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t S Received By January 31 ❑ Jul 1 S Rece d B I <br />I V__ / (-'—/ <br />—/ -d 1 <br />d by <br />9.&.WeDate RecelPl Nd: Permit No -- Issuance Dab Muted Delivered <br />APPLICANT—RETURNALLCORMa TQ ENVUEONIAVOTA 1EI PERMIT/SERVICES 11101 E. HAZELTON AVE., P.O. ser ]oeE BTOCKTON, CA NMI <br />s4uht <br />Y <br />Ive yJu Y31 <br />BASE <br />E%PLANATION <br />BILLING REMITTANCE <br />S <br />REMIT <br />DATE DATE <br />REMITTED <br />AMOUNTDUE <br />CHECKED <br />AMOUNT <br />FEE <br />, QV <br />`J /^O J <br />J Q <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />�( <br />OTHER <br />OTHER <br />I V__ / (-'—/ <br />—/ -d 1 <br />d by <br />9.&.WeDate RecelPl Nd: Permit No -- Issuance Dab Muted Delivered <br />APPLICANT—RETURNALLCORMa TQ ENVUEONIAVOTA 1EI PERMIT/SERVICES 11101 E. HAZELTON AVE., P.O. ser ]oeE BTOCKTON, CA NMI <br />s4uht <br />