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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL ENGINEER'S AND/OR APPLICANT'S AND/OR APPLICATION IF VEHICLE INVOLVED, GIVE CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make BROKER AND/OR Lic. No. LICENSE AND/OR FOOD ESTABLISHMENTS. HOUSING REGISTRATION PUBLIC POOLS. NATER SAMPLING Regist. No. NUMBER REAL ESTATE INSPECTIONS Color POULTRY RANCHES AND KENNELS f/�r ,Buslpess/Name To.Appear On Permit MISCELLANEOUS SERVICES Application Date / A ��';r r/ , FType Permit/Service Requested: !l�E�/'/ '%"�I %�t ."� Applicant Name / _ Address T Business Tele hone No.l'O�� d' ��U r a. / p Emergency Telephone No ILProperty'Location/Address /�' / iProperty Owner� _Address Operator's Name " _ Address _ 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE ❑ FOOD CROP HARVESTING/No. of Field Employees ALL APPLICANTS: Total Employees Including Operators 2. HOUSING ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY 13 MOBILE HOME PARK/No. of Spaces 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL �� I ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER I� NO. OF PUBLIC SERVED (Connections) 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds ❑ KENNEL/Runways /Animal Population No. _ No. of Confining Cages Sewage Disposal Method Solid Waste Disposal Method Water Supply Source _ _ Animal Waste Disposal Method /73 8. �J CONSULTATION FEE ��> r V ' ❑ BUSINESS LICENSE 7. R PLAN CHECKING FEE 7 ' y ❑ DANCE PERMIT 8. REAL ESTATE REQUEST: Water Well Inspection Sample[] Title Company Sewage System Inspection ❑ Address _ Tele. No. Escrow No. Seller Seller Address Telephone No. Seller Agent Name Service Request For Date I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Heallt/th%j District. APPLICANT'S SIGNATURE X �� l� f Title (/! Date FOR DEPARTMENT USE ONLY Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 b Received By January 31 ❑ July 1 & Received By July 31 BASE EXPLANATION BILLING REMITTANCE' fTTED AMOUNT DUE REMIT CHECKED DATE DATE REMI AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER ReCewed by Dale r�pt No Permit No Issuance Date Mailed Delivered •oo� ir�ur—ocrnou ., , .-ne,rc ten. �....,. ..... ..�.. �....�.,...�,��.......�� "__" _ _ e 0 I W