Laserfiche WebLink
Applications WIN Be rreeww When Submitted Properly Completed. Be Sure To Sign The Application. <br />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 />rApplication Date 1-11-87 <br />!Type Permit/Service Requested: Remnl <br />SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br />APPLICATION IF VEHICLE INVOLVED, GIVE <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br />FOOD ESTABLISHMENTS, HOUSING <br />Lic. No. <br />PUBLIC POOLS, WATER SAMPLING <br />Regist. No. _ <br />REAL ESTATE INSPECTIONS <br />Color <br />POULTRY RANCHES AND KENNELS <br />❑ FOOD PROCESSING PLANT ❑ COMMISSARY <br />MISCELLANEOUS SERVICES <br />❑ BAKERY <br />Business/Name To Appear On Permit _ Al <br />Williamson <br />Business Telephone No. <br />Emergency Telephone No. <br />CA <br />iProperty Owner T.ibhey-Owene-Ford ompsLny <br />Address 5700 E T. <br />yiBe Ave F Te bropr rA.T95330 <br />LOperator's Name_I,ibbey—Ow&na—Fn TNt rnmrany <br />Address 500) F. T,nt118P <br />A % f T a th rnp CAA 9_5330 <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 <br />❑ ICE PLANT <br />❑ BAKERY <br />❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE <br />❑ BAR <br />❑ ITINERANT RESTAURANT <br />❑ CONFECTIONARY STORE ❑ FOOD SALVAGER <br />❑ FOOD DEMONSTRATION <br />❑ FOOD VENDOR <br />❑ VENDING MACHINES/No. of <br />❑ MOBILE FOOD PREP. UNIT <br />❑ VENDING VEHICLE <br />❑ FOOD CROP HARVESTING/No. of Field Employees <br />ALL APPLICANTS: Total Employees Including Operators <br />LESS <br />2. HOUSING <br />❑ HOTEUMOTEL/No. of Units <br />❑ CERTIFICATE OF OCCUPANCY <br />❑ MOBILE HOME PARK/No. of Spaces <br />PRORATION <br />3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br />❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br />NO. OF PUBLIC SERVED (Connections) <br />a. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br />S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br />❑ KENNEL/Runways _ <br />Sewage Disposal Method <br />Solid Waste Disposal Method <br />Water Supply Source <br />6. ❑ CONSULTATION FEE <br />T. ❑ PLAN CHECKING FEE <br />/Animal Population No. <br />No. of Confining Cages <br />_ Animal Waste Disposal Method <br />❑ BUSINESS LICENSE <br />❑ DANCE PERMIT <br />S. REAL ESTATE <br />REQUEST: Water Well Inspection 13 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 />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 rul/e/s1�an�d regulations of the San Joaquin Local Health District. <br />APPLICANTS SIGNATURE X aC%. W .LI.A�WIJI�./���_ Title Contractor Date 1-11-87 <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A R.Me Rv Jant rm al f'1 <br />A <br />rvo <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES INl E. N ELTON AYE., ►.O. e!a MM STOCKTON, G EMMI <br />BABE <br />EXPLANATION <br />BILLING <br />REMITTANCE <br />B <br />AMOUNTDUE <br />REMIT <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEE <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />A <br />rvo <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES INl E. N ELTON AYE., ►.O. e!a MM STOCKTON, G EMMI <br />