Laserfiche WebLink
Li <br /> _ a <br /> Appltoallons Will Be Prod When Submitted Property Completed. BA Sure Ta agn The Appllullo, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> EHGINEEWS ANO/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S ANGOR Make <br /> CONTRACTORANDVOR ENVIRONMENTAL HEALTH PERMIT/SERVICES -- <br /> BROKEAAND/OR Lid. No. -- <br /> LICENSE AND/OR FOOD ESTABLISHMENTS.HOUSING Regist. NO <br /> REGISTRATION FE1@UC POOU.WATER SAMPUNG <br /> NUMBER BEAT ESTATE INSPECTIONS Color <br /> POBLTO asOCNES AND KENNELS ' <br /> MISCELLANEOUS fFIBICFS _ <br /> rApplication Date Business/Name To Appear On Permit <br /> !Property <br /> Type Permit/Service Requested: <br /> Applicant Name Address <br /> Business Telephone No. Emergency Telephone No. <br /> Location/Address �c_." F <br /> Property Owner Address <br /> L Operators Name Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage RestauranL 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 /> ❑ HOTEUMOTEUNo. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/NO.of Spaces <br /> 1 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. No.of Confining Cages <br /> Sewage Disposal Method — <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> IS. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> T. ❑ PUN CHECKING FEE ❑ DANCE PERMIT <br /> IL REAL ESTATE <br /> REQUEST: Water Well InapectIOn❑ Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tale.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 rubs and <br /> �regulat�ions of�the <br /> eSSan Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE x Title -> h–s>t Date <br /> FOR DEPARTMENT USE ONLY <br /> FN Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a R. BY Jenwry 31 ❑ July 1 a Races BY Juh et <br /> REMIT <br /> SASE EXPLANATION BILLING REMITTANCE E AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE I>��C loCa�J• <br /> LESS <br /> PRORATION <br /> RSA <br /> PENALTY <br /> OTHER <br /> OTHER 7 <br /> Recened by Date Reuip No. Perin No tr ;"Dele MaAed Del Id x <br /> AMICANT–KETIIaNJ11Lr%JPYA`TO. EMinnONYEWAL HEALTH P[RYI111EAVICEa 1601 E.N I!LTON AVE-P.O.ae.3000 STOC CWC CA eels" N <br />