Laserfiche WebLink
+.. <br /> Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application- <br /> f SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> APPLICATION IF VEHICLE INVOLVED, GIVE <br /> ENGINEER'S AND/OR Make <br /> APPLICANT'S AND/OR <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Lic.No. - - <br /> BROKER AND/OR F000 ESTABLISHMENTS,HOUSING Regist. NO -- -- <br /> LICENSE AND/OR PUBLIC POOLS,WATER SAMPLING <br /> REGISTRATION/` S REAL ESTATE INSPECTIONS COIOf - - <br /> NUMBER - - POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES rEC 1 S 1071 <br /> ?Il(�llStrleS , TIC , <br /> FApplication Date A- ?5-86 Business/Name To Appear On Permit <br /> Type Permit/Service Requested: Tarik Removal <br /> ?191 Naw Dr <br /> Applicant Name " "-Ci57.0I1 71nduStl ES Tnc _ Address _`1 D>� <br /> _ Business TeJephon No. Emergency Telephone No. — <br /> N.—.fir 3Cra7^en �O 1 <br /> Property Location/Address :a1-..- l <br /> .',Property Owner ("Clden State Stee._ ._ Address <br /> L Operator's Name Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Sealing 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 /> Z. HOUSING <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 /> e. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. 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 /> S. ❑ CONSULTATION FEE ❑ 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 /> I hereby certify that 1 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 - - _ Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 A Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> E AMOUNT <br /> FEE 90- Dz) <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> nr� y-a y-,�� -7F 7 <br /> Meerved DY Dare RereiPt No. Permit No. Issuance Date Mallad Delivered <br /> AMLICANT-REfWM CA NEa.TO: E MONMENTAL HGLTH PERMIT/SERVICES ta0t E.HAIELTON AVE.,P.O.ba 7mNBTOCI{TON,CA tei81 u <br />