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1, 40 <br /> Applications WIII Be Processed When Submitted Properly Completed. Be 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/OR <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br /> BROKER AND/OR LIC. No. _ . <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,HOUSING Regist. No <br /> REGISTRATION PUBLIC POOLS,WATER SAMPLING g <br /> NUMBER REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> 9 / MISCELLANEOUS SERVICES `�1L /1 jai <br /> f Application Date /�'�/'�� Bnusiness/Na e To Appear On Permit 1�' ��d — �'Sl��-� <br /> Type Permit/Service Requested: I & <br /> i Applicant Name 'IF 1 � /U A/d_dress (O � ` - /��!�` - �so <br /> s. <br /> C/ B si ess Tele hone No. (0" _2' Emergency Telephone No.j& 7Z�W <br /> ,Property Locatiodress <br /> n/ ' <br /> Property Owner r l �• Address _ <br /> I Operator's Name Address ___ / <br /> AA <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 n ,, Ole <br /> � �/ <br /> ALL APPLICANTS: Total Employees Including Operators .-_ .__ _- __. _ 11A rC <br /> 2. <br /> ING <br /> 11OTES MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY �2 M0VA2./ <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 /> ❑ KENNEURunways /Animal Population No. .__ No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source Anjrf Waste Disposal Method <br /> B. 1!4CONSULTATION FEE J,IJZS LJ BzcUESl ESS LICENSE <br /> Y- — -------- <br /> 7. "PLAN CHECKING FEE -3 _ ❑ DA CE <br /> B. REAL ESTATE <br /> REQUEST Water Well Inspection Sample❑ 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 Date <br /> I hereby certify that Iave prep d this applicat' n that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws and es and regulations t an Joaquin Local Health District. <br /> / f/ <br /> APPLICANT'S SIGNATURE X Title ,, Date I I <br /> FOR DEPARRT USE ONLY <br /> Fee Is Due: C3 ANNUALLY ❑ PER UNIT PER SITE E H C3 January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT I <br /> BILLING REMITTANCE' STTED <br /> BASE EXPLANATION DATE DATE REMIAMOUNT DUE CHECKED <br /> ,t AMOUNT <br /> FEE �d�� �� C��✓ <br /> LESS <br /> PRORATION <br /> PLUS /1 <br /> PENALTY L <br /> OTHER <br /> OTHER <br /> n <br /> 0 <br /> Received by Date Receipt No Permit No. Issuance Date Mailed Delivered = <br /> APPLICANT—RETURN ALL COPJES,TO: ENV IENTAL HEALTH PERMIT/SERVICES 1801 E.HAZI AVE.,P.O.Box 2009 STOCKTON,CA 95201 W <br />