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" r <br /> Applications Will Be P05. When Submitted Properly Completed, Be Su rt fo Slgn The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/ORMake —-- <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Lic. No. --- <br /> BROKER AND/OR FOOD ESTABLISHMENTS,MOUSING <br /> LICENSE AND/OR PUBLIC POOLS,WATER SAMPLING Regist. No. — --- - <br /> REGISTRATION REAL ESTATE INSPECTIONS Color - --- <br /> NUMBER POULTRY RANCHES AND KENNELS <br /> ,. MISCELLANEOUS SERVICES <br /> [Application Date ^C�'-� Business/Name To Appear On Permit — <br /> .Type Permit/Service, �,uG-e d - --- � <br /> Applicant Name fif L> '�3 - Address - - <br /> Business Telephone No.X7 Emergency Telephone No. .-- <br /> iProperty Location/A dress <br /> _ i � <br /> ------------ <br /> dProperty Owner Address - --- <br /> Operator's Name1 rY Address i <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 <br /> ❑ HOTEL/MOTEL/No. of Units 13 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 /> Animal Waste Disposal Method <br /> Water upply Source <br /> S. Ga <br /> �CONSULTATION FEE ❑ BUSINESS LICENSE <br /> T. Ua PLAN CHECKING FEE ❑ DANCE PERMIT <br /> 8. REAL ESTATE <br /> REQUEST Water Well Inspection[3 Sample 13 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 <br /> ,�District. - <br /> APPLICANT'S SIGNATURE X _ Title 7Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 a ReceivedREMITu y 31 <br /> BASE EXPLANATION 'BILLING REMITTANCE` $ AMOUNT DUE CHECKED <br /> GATE DATE REMITTEDf� AMOUNT <br /> FEE / 0 C-) L- -- <br /> LESS <br /> PRORATION / 2 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> m <br /> OTHER <br /> " v <br /> h _ ` <br /> / o <br /> Received by Date Re( o Permit Nc. Issuance Dat Mailed Delivered <br /> m 7[ <br /> APPLICANT—RET]UMALLC'noa TO_ ERVIRON HEALTH PERMITISERVICES 1901 E.HAZELTON ,O.Box 2009 STOCKTON.CA 95201 <br /> w <br />