Laserfiche WebLink
Applications Will Be irocessed When Submitted Properly Completed. Be Slue To Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR <br /> APPLICANT'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br /> BROKER AND/OR LiC. NO. <br /> LICENSE AND/OR F000 ESTABLISHMENTS,HOUSING <br /> REGISTRATION PUBLIC POOLS,WATER SAMPLING Regist. No. <br /> NUMBER _ REAL ESTATE INSPECTIONS COIOf <br /> POULTRY RANCHES AND KENNELS - - <br /> MIECEIlAME0U3 SERVICES <br /> rApplication Date Business Name To A pear On Permit dat/Lrt.E�LcQ,�i c (d sei /ii <br /> k.Type Permit/Service Requested'1 (L J� —� <br /> 7 Applicant Namepi4%,e Ad ress u a <br /> YYYYt ._Business Tele pon N Emergency Telephone No. <br /> •j Property Location/Address 40A- s � \�_ !WMA <br /> i Property Owner—SA4,"C Addres S//".k <br /> L Operator's Name S6PrH2. Address S440IL4 1 <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 /> ❑ HOTEUMOTEL/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 /> 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 /> Water Supply Source _ Animal Waste Disposal Method <br /> S. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> T. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT _ <br /> S. REAL ESTATE <br /> REQUEST: Water Well Inspection E3 Semple 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 District. <br /> � & <br /> APPLICANTS SIGNATURE X Sal/ - Title Ow u a. .--• Date 0 - 12 '-Quo <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due.0 ANNUALLY 0 PER UNIT ❑ PER SITE 0 EACH ❑ January 1 A Received By January 31 0 July 1 a Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT DUE CHECKEDAMOUNT <br /> FEE TP 00 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> C,—>r— ��/i�81e "71gg o <br /> R bead y Date Receipt No. Pormil Nolauenea die IMINd palivelad i <br /> APPLICANT-RETUaMJLLCOaMaTO: Mu'-INMENTAL HEALTH PERMIT/SERVICES /aM E.MAZE'-�M AVE.,P.O.Boa SOOY STOCKTON,CA f w <br />