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Applications Will Be PoRssed When Submitted Properly Completed. Be Sur•Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br /> BROKER AND/OR LIC. NO. __— <br /> LICENSE AND/OR F000 ESTABLISHMENTS.MOUSING Re !St. No. <br /> REGISTRATION PUBLIC POOLS.WATER SAMPLING g <br /> NUMBER _. REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> _ MISCELLANEOUS SERVICES <br /> rApplication Date —� Business/Nam To Appear O^��?rmlt <br /> Type Permit/ServiceRequested: <br /> Applicant Name a � a � Address /g29S �irz�/�-nits-t Da/ <br /> !qJusiness Telephone No. G,Y-�O�s� Emergent elephone No. .� � <br /> Property Location/Address. <br /> Property Owner L' �/,//l7G? af/L Address .S�NtI� A2 CGe1l� _ <br /> L Operator's Name rr Address / r� <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 d <br /> ALL APPLICANTS: Total Employees Including Operators 3�$� <br /> 2. HOUSING G /� <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY / <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. 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 /> 5. 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 /> B. ❑ CONSULTATION FEE s t - ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> 8. REAL ESTATE <br /> REQUEST: Water Well IInspection❑ Sample 11 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 /> 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 tle Date 9 9 d <br /> FOR DEPARTME USE ONLY <br /> Fast Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 S Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> �y AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> AV Q-q-Fs <br /> 0 <br /> Received by Date Receipt No. Permit N. Issuance Date Mailed Delivered <br /> APPLICANT—RETU MJ1L1CONUELTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAIELTON AVE.,P.O.Box late STOCKTON,CA 95201 W <br />