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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign9e Application. <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'SR <br /> AND/ <br /> APPLICANT'S AND/OR APPLICATION IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br /> BROKER AND/OR Lic. No. <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> REGISTRATION PUBLIC POOLS,NATER SAMPLING Regist. No. <br /> NUMBER REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> Application Date lo iII Bust ess/Name To A � C Ccs un��n <br /> ppear On Permit <br /> in Type Permit/Service a ue ted; Lt�,Qn Fbf i)-e (1 <br /> i ApplicaAddress l <br /> u � (-' 1-140 -- � � _ Business Telephone No. �`� "� '� Emer ency Telephone No. L= <br /> Property Location/Address C. <br /> Property Owner�tP- t QA(f .Q~j - Address <br /> L Operator's Name Addressi�� _ <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 ❑ 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 /> ❑ M0131LE HOME PARK/No. of Spaces <br /> 3. WATER ANALITY ❑ 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 /> ❑ KENNELIRunways /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 /> G. tCONSULTATION FEE &5,00 BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> B. 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 /> 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,anyi r es and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE i 1 Titlel Vv�r'S-P) f�� k.-�l Date V 4 �✓T" _ <br /> "I FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 a Received By July 31 <br /> BILLING REMITTANCE' j REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE .��r 00 ©v <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER yr 7 <br /> e <br /> OTHER m <br /> ti <br /> C%-3. <br /> Received by Dale Receipt No Permit N0 Issua ce Dete Mailed 9 <br /> Delivered = <br /> APPLICANT—RETL LN ANL CLE-TO: MENTAL HEALTH PERMIT/SERVICES 1601 E.H* <br /> AVE..,P.O.Bae 2009 STOCKTON,CA 95201 W <br />