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y r1 <br /> Applications Will Be Processed When Submitted properly Completed.Be Sure Sign The Application. <br /> • SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR Make --- <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Lic. No. -- <br /> BROKER AND/OR FOOD ESTASLISNMENTS,HOUSING <br /> LICENSE AND/OR PUBLIC POOLS,MATER SAMPLING Regist. No. — <br /> REGISTRATION <br /> NUMBER REAL ESTATE INSPECTIONS Color <br /> NUMBER POULTRY RANCHES AMO KEN <br /> MISCELLANEOUS SERVICE3 <br /> rApplication Date Business/Name To Appear On Permit — —�-- <br /> ,ua itamfe _ �._ <br /> U GC ICJU <br /> Type Permit/Servic equ ste Address liNergTelBusl Telephon o. e o. <br /> enGy <br /> Property Location/ ddress <br /> ._9d <br /> Property Owner Address <br /> L Operator's Name ! VZ 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 /> Water Supply Source Animal Waste Disposal Method <br /> 6. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> T. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> e. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ Sample❑ Tithe 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 Localealth District. <br /> I <br /> APPLICANT'S SIGNATURE '� Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 a Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> /y DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> ,f j � <br /> OTHER <br /> r3 <br /> � tLl4.3 I n <br /> A p � <br /> Recefyed by Date Receipt No. Permit No, Issuance Date Mailed Delivered = <br /> APPLICANT—RETIJM ALLCOVA&Te: ENVIRONMENTAL HEALTH PERMITISERVICES Joel E.HAZELTON AVE.,P.O.tloa 2009 STOCKTON,CA 25301 - W <br />