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Applications Will Be Processed When Submitted Property Completed.Bs Sure To Sign 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 /> — -- -- — -- <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br /> LiC, No. <br /> BROKER ANO/OR FOOD ESTABLISHMENTS,HOUSING <br /> LICENSE AND/OR PUBLIC POWATER SAMPLING Raglel. NO. <br /> OLS. - -— ---- - <br /> REGISTRATION REAL ESTATE INSPECTIONS Color .----- <br /> NUMBER --. POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> FApplication Date_-_ _ - Business/Name To Appear On Permit ____ --------- - -- - <br /> *Type Permil/Service Requested: - - <br /> Applicant Name Stockton Service dloll—EqUUI11Mtddress_.80B N.Uni-on_$t.,_.StD-Ckt0n-- -- - <br /> Y --- <br /> ._ Business Telephone No. Emergency Telephone No. ----- —-- <br /> (Property Location/Address 2716 E. Miner_StQLk_t-0b.-----T— ------- ---- - <br /> �Property Owner Del Monte �QY'D. —_—___ Address <br /> I Operator's Name Address _—_ --- ---- <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 ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces <br /> S. 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 , �, c> <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 /> D. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> T. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT -----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 Onto _ <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 Date <br /> FOR DEPARTMENT USE ONLY <br /> I F• 'n Out: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I a nweived By January 71 ❑ July/S Received By July 71 <br /> REMIT <br /> BASE EXPLANATION BILLINGMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE HEMMED AMOUNT <br /> FEF _ $90.00 Tank Remo al — — $90.00 X _ <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Com �iy b __No �3nr° <br /> Rxeived by ipt No. Pormil No. IMuan a Melted Oellwmd I <br /> APKICANT—RETUaM1 GODNHL TO: E MENTAL HEALTH PERMITAIERVICES Lal E.HA2 VE.,P.O.Roo SSSa STOCxTOR.CA""q ---- <br />