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Appmetions WIII Be p�seed When Submitted Properly Completed.Be Soo Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> IF VEHICLE INVOLVED, GIVE <br /> ENGINEER'S AND/OR APPLICATION Make -- <br /> APPLICANTS AND/OR <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICE Lid.No. <br /> BROKER AND/OR FOOD ESTABLISHMENTS,HOUSING Regist.No.� <br /> LICENSE AND/OR PUBLIC POOLS,MATER SAMPLING Color <br /> REGISTRATION REAL ESTATE INSPECTIONS <br /> NUMBER POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES v10G <br /> rApplication Data Z3 ,g Business/Name To Appear On Permit /. <br /> G aoAd .4 po <br /> ,Type Permit/Servic,¢Reqquuested: ress dO d <br /> Applicant Name iii/��v t4f �o N-!l <br /> A <br /> B sines Tale It ne No. � -2 2 Emergency Telephone No. <br /> 7; <br /> Property <br /> Property Location/dress <br /> Property Owner S/D ri .ei4yN�OND Address <br /> Address <br /> L Operator's Name <br /> ge Restaurant, <br /> 1. FOOD ESTABLISHMENTS Total Building Sq.footaALE Maximum Seating Capacity <br /> SALE <br /> 0 RESTAURANT 13 FOOD MARKET RETAIL ❑ FOOD MARKET WHOLE11 MEAT MARKET <br /> ❑ COMMISSARY 13 ICE PLANT ❑ BAKERY <br /> [3 FOOD PROCESSING PLANT ❑ ITINERANT RESTAURANT <br /> [3ROADSIDE FOOD STAND 13 LIQUOR BAR LIQUOR STORE 13FOOD VENDOR <br /> ❑ CONFECTIONARY STORE 13 FOOD SALVAGER 11 FOOD DEMONSTRATION <br /> ❑ VENDING MACHINES/No.of <br /> ❑ MOBILE FOOD PREP.UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No.of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2 HOUSING ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ HOTEVMOTEL/No.of Units <br /> ❑ MOBILE HOME PARK/No.of Spaces . . ❑ CHEMICAL <br /> 3. WATER QUALITY ❑ WATER SAMPLE(Bacterial) <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER _ <br /> NO.OF PUBLIC SERVED(Connections) <br /> 4, RECREATIONAL HEALTH ❑ SWIMMING POOL 13 SPA <br /> ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds Na o1 Confining Cages <br /> E3KENNELJRunways /Animal Population No. <br /> Sewage Disposal Method _ <br /> Solid Waste Disoosal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> y 13 BUSINESS LICENSE <br /> 6. (p(CONSULTATIQM FEF97( 13 DANCE PERMIT <br /> 7. pIPLAN CHECKING FEE <br /> a. REAL ESTATE <br /> REQUEST: Water Well Inspection E3 Sample❑ Title Company Tele.No. <br /> Sewage System Inspection 13 Address <br /> Escrow No. <br /> Seller Seller Address <br /> Telephone No. Seller Agent Name <br /> Service Request For Date <br /> I hereby certify that 1 have ared this application and that the work will be done in accordance with Sen Joaquin County <br /> ordinances,state laws,a rul and gula ons of Ke Joaquin Local Health District. <br /> APPLICANTS SIGNATURE X <br /> Title !��- Date S 23--'- <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 13 EACH ❑ January 1 A R—i—I BY January 31 ❑ July 1 A Received ByJuly 31 <br /> REMIT <br /> REMITTANCE S AMOUNT DUE CHECKED <br /> BASE EXPLANATION BILLING <br /> Q DATE DATE REM�1ITTED AMOUNT <br /> FEELESS <br /> 7O KV•UO <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> uno s Z7-scL t <br /> .� by Dete Receipt No. Pa t NO. In Gate Me led Delivered i <br /> APPLICAMT—RETUaN•r, CCMESTO: ENVIRONMENTAL HEALTH PERMRBERwCEE ta01 E 11AZELTON AVE.P.O.aea IDOS STOCRTW4 GfS7a1 <br /> w <br />