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Applications WIII Be Pr When Subnllted Property Completed. Be Sure To The Appllcallon. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGAPPI.ICCANT'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> CONTRACTOR AND/oR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br /> BROKER AND/on <br /> Lid.No. <br /> LICENSE AN01011 1000 ERTABUSHMENTI,HOUSING <br /> REGISTRATION PUBLIC►BOIL,WATER SAMPLING Regist. No. <br /> NUMBER REAL ESTATE INSPECTIONS Colm <br /> POULTRY RANCHES AND KENNELS <br /> N=EU"EOUS SERVICES <br /> Application Data 7l Bus' ass/ ame TO� J`1 Appear On Permit <br /> !Property <br /> Type Permit/ServiceRequested:Applicant Name fr�.PiJ8tC0 ` Address usinessielephone No, -LocatiorVA�dr�+ fL-e GGA <br /> Property Owner11, NT LAddress_&1 7��- ly �. Z3`II- <br /> LOperator's Name Uri �� Address /fir 1 Q/ "11" i-11 11�le <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 /> ❑ HOTEUMOTEUNo.of Units ❑ CERTIFICATE OF OCCUPANCY <br /> Cl MOBILE HOME PARK/No.of Spaces <br /> i 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 /> L Z CONSULTATION FEE r�r Com0 BUSINESS LICENSE <br /> T. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> L REAL ESTATE <br /> REQUEST: Water Will inspection 13 Sample❑ Title Company _ <br /> Sewage System Inspection ❑ Address Tele.No. <br /> Eacrow No. <br /> Seller Seller Address I <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 accordan�-wfth San Joaquin County <br /> ordinances,state laws,and rules an tiom of the n Jwquin Local Heat Diatri 1 / <br /> Z7 <br /> APPLICANTS SIGNATURE X'�' i ��/� TitleDale <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑PER UNIT ❑ PER SITE ❑ EACH ❑ January I A A.n*d By January 31 ❑ July 1 A Raco By Jule 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE f AMOUNT DUE CHECKED <br /> q DATE DATE REMITTEDUN <br /> / AMOT <br /> FEE i% . 0.4 LI/Lr� r <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7 <br /> Rsc by Dais R*C,upt NO. h.,I No. Isauancs One Mailed Dellwred i <br /> AMICAIHT—aFTDaNALLCOPIFA�TO: FJIYMOMYFMAL NEALIN PFaYITra[awCFa lqt G MAZ[LTOM AYH_P.O.ser qq STOCKTOH,CAaaml Y <br />