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ENGINEER'S AND/OR <br />APPLICANT'S AND/OR <br />CONTRACTOR AND/OR <br />BROKER AND/OR <br />LICENSE AND/OR <br />REGISTRATION <br />NUMBER <br />[Application Date <br />*Type Permit/Sen <br />Applicant Name . <br />O <br />J gProperty Locatio <br />Property Owner <br />L Operator's Name <br />Applications WIII Be P141 hen Submitted Properly Completed. Be SUAorhe Application. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />FOOD ESTABLISHMENTS. HOUSING <br />PUBLIC POOLS WATER SAMPLING <br />REAL ESTATE INSPECTIONS <br />POULTRY RANCHES AND KENNELS <br />MISCELLANEOUS SERVICES <br />- Appear O1n_Perm <br />Business Telephone No. <br />Address <br />Address <br />GENERAL <br />IF VEHICLE INVOLVED, GIVE <br />Make <br />Lic. No. <br />Regist. No.--- <br />Color-- <br />Emergency <br />o. -- <br />Color — <br />Emergency Telephone No. <br />1. FOOD ESTABLISHMENTS <br />Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br />❑ RESTAURANT ❑ FOOD MARKET RETAIL <br />❑ FOOD MARKET WHOLESALE <br />❑ MEAT MARKET <br />❑ FOOD PROCESSING PLANT <br />❑ COMMISSARY <br />❑ ICE PLANT <br />❑ BAKERY <br />❑ ROADSIDE FOOD STAND <br />❑ LIQUOR STORE <br />❑ BAR <br />❑ ITINERANT RESTAURANT <br />❑ CONFECTIONARY STORE <br />0 FOOD SALVAGER <br />❑ FOOD DEMONSTRATION <br />❑ FOOD VENDOR <br />❑ VENDING MACHINES/No of <br />❑ MOBILE FOOD PREP. UNIT <br />❑ 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 <br />❑ 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 <br />❑ 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 <br />Solid Waste Disposal Method <br />No. of Confining Cages <br />WaIZr.,,Supply Source Animal Waste Disposal Method <br />OLCONSULTATION FEE ❑ BUSINESS LICENSE <br />7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br />S. REAL ESTATE <br />REQUEST: Water Well Inspection Sample❑ <br />Sewage System Inspection ❑ <br />Escrow No. <br />Seller <br />Telephone No. <br />Service Request For Date <br />Title Company <br />Address <br />_ Seller Address <br />Seller Agent Name _ <br />Tele. No. <br />I hereby certify that I have prepared this ap licatlon and that the work will be done in accordance with San Joaquin County <br />ordinances, sta and rules and regu=Of Joaquin Local Health District.f //���� L�APPLICANT'S SIGNATU4 /Itis 4Title 3�'- Dale �.i_.N'/ Wf <br />FOR DEPARTMENT USE ONLY If <br />Fast la Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 S Received By July 31 <br />REMIT <br />BASE <br />EXPLANATION BILLING <br />REMITTANCE <br />E <br />AMOUNT DUE <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEE <br />�7 <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />I <br />OTHER <br />OTHER <br />N) P <br />Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br />.. — ... .... n.cn .n. ue...0 eeeu,..eeeu,nee .... I., fl,Y euC Or, On.. 6TMI[TnY na.., <br />