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Ap111cc11one C'aid Ce Pru"seed`.,hzm Submlttcd Properly Completed.ee Sure To Sign The Application. <br /> SAN aOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEERS AND70R <br /> APPLICANTS AND/ORAPP LS CAT!ON IF VEHICLE INVOLVED, GIVE <br /> JTRACTOR AND/OR ENVIROMMENTAL HEALTH FERIMITiSERVICES Make <br /> ;KER Arlo/OR LIG.NO. <br /> i.,CENSC AND/OR '.ST.".JU.i.'iiSiT.^,.: Y:^:I;]S REGISTRATION ?0=P3CLP..^ �,,,,. Regist. No. <br /> — <br /> NUMBER ll= Z TFTs I • '•,' Color_ - <br /> ' PC,LT.:Y n. ..o AI.,. XELS <br /> PIZDELLANEOJS SEA4ICES `�I l t^ <br /> Application Date _-- Business/Name To Appear On Permit <br /> mType Permil/Sorvice Requested ---- <br /> Appllcant Name Atltlress I11 , r - T--_- <br /> ' Business Telephone �•} c/�7 <br /> Property Location/Address //+ f^ ''' Eme/rgency Telephone No. <br /> Property Owner r t 1'Z <br /> - �7. Address {7 7itt-yf�...-21 <br /> nr75- <br /> wi <br /> L Operator's Name - ,- �" .(� 'I; ,:.,1 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 /> ;i 2. HOUSING <br /> - ❑ HOTEL/MOTEL/No.of Units - ❑ CERTIFICATE OF OCCUPANCY - - <br /> ❑ MOBILE HOME PARK/No.of Spaces _ <br /> WATER QUALITl ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED(Connections) <br /> 3 - 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> VICTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds <br /> KENNEL/Runways iAnimal Population No. No.of Confining Cages <br /> Sewage Disposal Method _ <br /> Solid Waste Disposal Method <br /> ,. Water Supply Source / Animal Waste Disposal Method <br /> 6. •`CONSULTATION FEE -rn�i:).-.. •: '� ter, h ;ri ❑ BUSINESS LICENSE <br /> 7. 11PLAN CHECKING FEE ,P ❑ DANCE PERMIT <br /> -T <br /> S. REAL ESTATE <br /> 1 REQUEST: Water Well Inspection❑ Sample❑ Title Company <br /> ? Sewage System Inspection ❑ Address Tele.No. <br /> y <br /> '3 Escrow No. <br /> Seller Seller Address _ <br /> Telephone No. Seller Agent Name <br /> Service Request For Date _— <br /> r' <br /> -,� 1 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 /> APPLICANTS SIGNATURE tX r/ �� �Titlo�-�� `%rf l.-hi./..Date �� :n�.��_ <br /> FOR DEPARTMENT USE ONLY , <br /> �! Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31, ge`I 1 I July at <br /> BILLING REMITTANCE 1 'I✓ IT <br /> BASE EXPLANATION DATE DATE REMITTED " AMOUNT DUF _ KED <br /> A NT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS�! PENALTY <br /> OTHER __�`., r ENVIRONMENTAL'✓IRONN;[NTAL �ALTrF-' <br /> 7 C• U Ili -F. r I <br /> i <br /> 'ti 3 <br /> OTHER <br /> Raeeivatl Dy nate neeeiy;No yernnt No Issuance Date Milled Delivered <br /> APPLICANT-EETL'^..NdLl.CG5ST0: ati`:IC0:.4r3ilTAL HEALTH PEERiR!aiftV10E5 1601 E.HAZELTOH AVE.,P.O.Eos 20Da S"i OCSTON,CA 95201 <br />