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Applications Will Be Pre wed When Submitted Properly Completed.Be Sure Ign The Application. <br /> SA1V JOAOUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANTS ANO/OR <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make —_ <br /> BROKER ANO/OR LIC.NO. <br /> LICENSE AND/OR FOOB ESTABLISHMENTS,HOUSING <br /> REGISTRATION PUBLIC POOLS,WATER SAMPLING Regist.No. _ <br /> NUMBER REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES ANO KENNELS <br /> M_Ii�fELLAMEOU!SEIIYICES I � <br /> rApplication Date " Business/Name To Appear On Permit � a I tick i/J <br /> ,aType Permit/Service Requested: / PLL/�5 <br /> iApplicant Name �S�"74c1 !•*eJ6 C.:r. i lld`�A dress- &0 nIM 6-(.tie"Ca <br /> 1F Business Telephone Noo t��� �3 Emergency Telephone No. <br /> Property Location/Address �j3 i� J!_ f l G <br /> i Property Owner TC _,H P.tl (Z,�1 V" Address 3 '7 3 G /17 i1; c!2 D v <br /> L Operator's Name sEj/&y!E 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 r <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 GJ` <br /> 2. HOUSING 4u <br /> ❑ HOTEL/MOTEL/No.of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces fL� )6 v <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 v / <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds <br /> ❑ KENNEL/Runwsys /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 /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> S. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 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 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 <br /> District. <br /> APPLICANTS SIGNATURE X TitleDate <br /> T' c <br /> fsl 2.�f�f <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1&Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE' $ AMOUNT OUE CHECKED <br /> DATE. DATE REMITTED AMOUNT <br /> TE <br /> FEE © n V+I. C�O <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> Y <br /> OTHER <br /> C �/13 B co 13`1 o <br /> 0 <br /> Received by Date Receipt No. Permit No. lasuance Date Mailed Delivered = <br /> APPLICANT—RETURMALLCORIES.TO: ENVIaONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.box MM STOCKTON.CA 06201 I W <br />