Laserfiche WebLink
Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S ANO/OR Make <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> BROKER AND/OR LIC. No. --- - <br /> LICENSE AND/OR F000 ESTABLISHMENTS.HOUSING Regist. NO. <br /> REGISTRATION PUBLIC POOLS WATER SAMPLING g - <br /> NUMBER REAL ESTATE INSPECTIONS Color --— <br /> POULTRY RANCHES AND KENNELS <br /> O MISCELLANEOUS SERVICES <br /> rApplication Date©7- D J Business/Name To Appear On Permit - t/0jD.C1Z 6&QU A1N& 0 UES <br /> a Type Permit/Service Requested: UAI T)E_-�WA9D 7WAW ZF/710 dE.lC <br /> Applicant Name C l7Y 0 F 146zlAddress n-21 <br /> u Business Telephone No. Emergency Telephone No. <br /> Property Location/Address S/SlO� <br /> Property Owner ©F .L b D/ . Address <br /> L Operator's Name Rja' th �_ /Z .SZ Address <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 -e[ <br /> ❑ HOTEVMOTEVNo.of Units 13 CERTIFICATE OF OCCUPANCY l/'W <br /> ❑ MOBILE HOME PARK/No.of Spaces <br /> 3. WATER QUALITY ❑ WATER SAMPLE(Bacterial) ❑ CHEMICAL D y <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 /> ❑ KENNEVRunwaye /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source o ti Animal Waste Disposal Method <br /> 6. jft CONSULTATION FEE BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> S. 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 I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state lawd rules and regulations of a an Joaquin Local Health District. T fir. J <br /> APPLICANTS SIGNATURE &L' TitleDate <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 /> REMIT <br /> E <br /> BASE EXPLANATION BILLING REMITTANCE" AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION Vol <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Ferrell No, Issuance Date Mailed Delivered t <br /> APPLICANT—RETIJB COB 70, ENVMONMENTAL HEALTH PERMIT/SERVICE! 1 Wd E.HA VELTON AYE.,P.O.ba BSOS StOCKTON,CA SSSet w <br />