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. ,Y Appllcallone WIN M PAL Wh— Sub -111"d Property Compl►ted. Do Swec Tha AppAcaUcn_ <br />ENOMrtEtI►s ^1410"Y <br />SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br />APPLICANT'S AND/0n1 APPLICATION IF VEHICLE INVOLVED. GIVE <br />CONTRACTOR ANDIDR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br />OPOKEA AND/OR -- <br />LICENW ^ND''011 ►Bee MAA IRSaft IrT1, MevslMa Lid. No. <br />REGISTRATION PUKX POOLS, MATIN ILAM/UM Regiat. No. <br />NUMBER LC 1, - /L,2=—O—L_--- MULL EZYATE IRiPECT10Ms — <br />PeKITaT AAIICM A" KE"E" Color <br />M1sLt1LANt0tp SESVICts <br />Application Date Business/Name To Appear On Permit CW'j>Tp <br />.Type Permit/Service Requested:._ Z9�%1% Lt1E✓ <br />Applicant Name <br />Address _-�� W � f, <br />Busii ss Telephone No.. Za- ZS Emergency Telephone No. �/3 -77 <br />Property LOcation/Address c]�i/77e S ?x,c rr�l,� <br />Property Owner 'SizIle- Address /DZi/ C✓ Cd�la/iD�>d y�. s� ' mH <br />l OperatorsNams��,�yt �� (�/su---_-_44wCti. Address �de�-. Z�//>t$/�iAc,,� ,per/ori C <br />Od <br />1. FOOD ESTABLISHMENT& Total Building Sq. Footage Restaurant, Maximum Seatkhg 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 />L HOLMNG <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 />S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br />❑ KENNEL/Runways /Animal Population No. <br />Sewage Disposal Method No. of Confining Capes <br />Solid Waste Disposal Method <br />Water Supply Source Animal Waste Disposal Method <br />& ❑ CONSULTATION FEE❑ BUSINESS LICENSE <br />7. PLAN CHECKING FEE ❑ DANCE PERMIT <br />i REAL ESTATE <br />REQUEST: Water Well Inspection❑ Sample❑ Title Company <br />Sewage System Inspection ❑ Address <br />Escrow No. Tele. 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 ru d r u Ions of the San Joaquin Local Health District. / <br />APPLICANTS SIGNATOR X / Title Date <br />FOR DEPARTMENT USE ONLY <br />Fee Is Duo: ❑- ANNUALLY ❑ PER UNIT I] PFR rITF 11 C.1- rt <br />FEE <br />BASE <br />EXPLANATION <br />BILLING <br />DATE <br />REMITTANCE <br />DATE <br />.._..�..�...,r __7s <br />1 <br />REMITTED <br />- __- ---- -- <br />u Jury I a <br />AMOUNT DUE <br />RecMvW BY July 31 <br />REMIT <br />CHECKED <br />AMOUNT <br />LESS <br />- <br />- - --- <br />-- <br />-- <br />-_._..--.-_-- <br />PRORATIQN <br />PLUS <br />'ENAI TV <br />DTHER <br />3THER-- <br />W - - <br />HK.w�pl NO Vw.mil NO <br />I�awnc• DwIF W.1wd D.+n...q _--___ <br />APVLICANT—Nr TUYNA1A-W-&1 TO-, fM LRONYf NTAL HIALTH PfAYIT'lfwVICrr 1601 F. MAXELTON AVt_ ►.O. b• ]DW <br />.TOCKTnK CA 9,)'e, <br />