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-`a Applications WIII Be PIJJad When Submitted Properly Completed.Be Sureu,lgn The Application. <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> ENGINEER'S AND GENERAL <br /> APPLICANT'S ANDIOR APPLICATION IF VEHICLE INVOLVED, GIVE ' <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br /> BROKER AND/OR -- <br /> LICENSE AND/OR J FOOD ESTADUSHMENTS.HOUSING - Lis. No. <br /> NUMBER <br /> REGATION —.C/j'/ �— PUBLIC POOLS.MATER SAMPLING Regist. No. __ -_- <br /> 1 E REAL ESTATE INSPECTIONS <br /> POULTRY RANCHES AND KENNELS Color <br /> rAppliCation Date �� MISCELLANEOUS SERVICES <br /> J Busing s/Name To Appear On Per it <br /> ;Type Permit/Service Reque t d: _A- I\p'y+o./nQ� -_ 'vim/ter'+' I,-) <br /> ----- <br /> Applicant Name -. Ad ress ay 7 <br /> Bust ss Telephone N 65e - _ <br /> P 'YL . <br /> --�. Emergency Telephone 6 <br /> Property Location/Address g Y e ephone No.. <br /> � <br /> dProperty OwnerPLI -e- y1 Address Lgml <br /> L Operator's Namey a Addressq2q <br /> 1. FOOD ESTABLISHMENTS Total Building Sq, Footage Restaurant,Maximum Seating Capacity I <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET f <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 <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING _ <br /> ❑ HOTEL/MOTEL/No.of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARKINO.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 /> e. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds <br />•1 <br /> ❑ KENNEVRunways /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Wter Supply Source _ Animal Waste Disposal MethodY <br /> 6. CONSULTATION FEE llwo 13s BUSINESS LICENSE fkf11 <br /> 7. ❑ PLAN CHECKING FEE DANCE PERMIT <br /> f S. REAL ESTATE <br /> r REQUEST: Water Well Inspection 13 Sample 13 Title Company <br />'. Sewage System Inspection ❑ Address Tele. No. I <br /> Escrow No. .I <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 W7#/.PP lea andrr r'-I^• '•'•e San Joaquin Local Health D rict. <br /> APPLICANTS SIGNATURE \.YG_-t :- `� .—_ Tiff .!f' Date <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT - ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 A Received By July 31 <br /> BILLING REMITTANCE S REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ., 3x•(10 . <br /> LESS <br /> PRORATION <br /> PLUG 11 <br /> PENALTY taw, <br /> Tq <br /> OTHER <br /> OTHER <br /> I <br /> Received by Date Receipt No. Permd No. luuenoe Dale - Mailed Delivered i <br /> APPLICANT—RETUaNALLOOMELTO: EN OMMENTAL HEALTH PERMIT/SERVICES 18011 E.HAZELTON AVE..P.O.Doa 2008 STOCKTON.CA 83201 1 w <br /> 5 ) <br />