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Applications WIII Be PVOC When Submitted Properly Completed.Be Sure To Sign The Application. <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR <br /> APPLICANTS AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> CONTRACTOR <br /> BROKER AND/OR D/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make. <br /> LICENSE AND/OR FOOD ESTABLISHMENTS.NOUSINO Lic. No. <br /> REGISTRATION J� �/ //j <br /> /y Pj/c7 PUBLIC PUUId•WATER SAMPUMS Regist. No. <br /> NUMBER REAL ESTATE INSPECTIONS Color_ <br /> POULTRY RANCHES AND KENNELS <br /> r— MISCELLANEOUS SERVICES <br /> rApplication Datej. Business/Nam Ty Appear Qn Permit _ <br /> TYpe PermiVSeryice Requ sted <br /> i Ap Iicant Name c Atl_ ess'y /� —0 Los, <br /> o C/ <br /> ._ Bu i ess Telephone o 6J 9-0�0 Emergency Telephone No. 3 � <br /> Property Location/Ad r s J�� ` � 7 <br /> Property Owner B --_ Address. I � _7 <br /> L Operator's Name <br /> Address �$ T�—i-n <br /> /. FOOD ESTABLISHMENTS Total Building Sq. Footage <br /> Restaurant,MUximSfrl Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIOUOR 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 /> Z. HOUSING <br /> ❑ HOTEL/MOTEL/No.of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces <br /> S <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) El CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED(Connections) <br /> A. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. 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 /> Wa er Supply Source Animal Waste Disposal Method <br /> 6. CC0NSULTAT10N FE EQ4.c s n :FJ ❑ BUSINESS LICENSE <br /> T. ❑ PLAN CHECKING.FEE ❑ DANCE PERMIT <br /> S. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample 13 Title Company <br /> Sewage System Inspection ❑ . Address Tele. No. <br /> Escrow No. k <br /> Seller Seller Address <br /> Telephone No. Seller Agent Name <br /> Service Request For Date <br /> I hereby car ity that I have prepared this application and that the work will be done in accordance with San Joaquin County - <br /> ordinances,state laws,and ru andllJ g atio a of the in Local Health 1191, <br /> APPLICANT'S SIGNATURE X - / _ Titles Date _7 , <br /> FOR DEPARTMENT USE ONLY <br /> FOR Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Reeeivad By January 31 ❑ July 1 a Received By July 31 <br /> BILLING REMITTANCE f REMIT <br /> BASE - EXPLANATION DATE DATE REMITTED AMOUNTDUE CHECKED <br /> AMOUNT <br /> FEE �$.U_0 <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY (e <br /> OTHER L+✓L _ ! <br /> OTHER /� <br /> �y <br /> Recened MDate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICAM—RETLaM�COMFI TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES loaf E.HAZELTON AVE.,P.O.Box]008 STOCKTON,CA 85101 w <br /> �! I <br />