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Applications Will Be Processed When Submitted Properly Completed.Be Sure 7o Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR <br /> APPLICANT'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVECONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br /> BROKER AND/OR Lid. NO. <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> REGISTRATION PUBLIC POOLS,NATER SAMPLING Regist. No. <br /> NUMBER REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> / MISCELLANEOUS SERVICES <br /> r Application Date /Z � Business/Name To Appear On Permit <br /> Type Permit/Service Requested: <br /> uApplicant Name r r X i CAddress / c d <br /> _._ Business Telephone Na-0` - — mergency a ep n one 1110. <br /> iProperty Location/Address <br /> 'ji Property Ownerx;t is i/ C� Address/f <br /> L Operator's Name Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> 0 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 ❑ 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 /> W ter Supply Source Animal Waste Disposal Method <br /> 6. 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 laws,and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X. -- Title 'J'r P, Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i&Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE' E <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> of AMOUNT <br /> FEE �, / 10C/ <br /> LESS <br /> IN / <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> a <br /> OTHER <br /> CCC�i� O <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURNALL.CORIES.TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95401 W <br /> u, <br />