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Appilcatlons WI1•^9 Processed When.SubmittedProperlyCompltlea. sure Ivolio" 1t-..rr•• k i f JOAQUlN LOCAL HEALTH DIS'�;r_ GENERAL ENGtHEER•S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE APPLICANT'S AND/ORMake -- CONTPACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Lic. No. -- BROKER AND/OR 9000 ESTABLISHMENTS,HOUSING LICENSE AND/OR ►UBLIG TOOLS,WATER SAMPLING Regist. No. REGISTRATION REAL ESTATE°INSPECTIONS Calor NUMBER POULTRT RANCHES AND KENNELS MISCELLANEOUS SERVICES FApplication Date _. Business/Name To Appear On Permit — -- = Type Permit/Service Requested: — V Applicant Name ;' T Address - - _ Business Telephone No. Emergency Telephone No. eL Property Location/Address — {Property Owner Address L 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 ❑ LIOUOR 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 4 2. HOUSING ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY ❑ MOBILE HOME PARK/No.of Spaces 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER NO. OF PUBLIC SERVED (Connections) 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds ❑ KENNEL/Runways /Animal Population No. " No.of Confining Cages cc Sewage Disposal Method - -2L1 Solid Waste Disposal Method Water Supply Source Animal Waste Disposal Method 6. ❑ CONSULTATION FEE © BUSINESS LICENSE 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT. S. REAL ESTATE REQUEST: Water Well Inspection 13 Sample Title Company - Sewage System Inspection ❑ Address Tele. o. • Escrow No. Ip \\\ Seller Seller Address _ Telephone No. Seller Agent Name b 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 Health District. {: APPLICANT'S SIGNATURE X" Title - Date - - FOR DEPARTMENT USE ONLY Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE - ❑ EACH ❑ January1 A Received By January 31 „ ❑ July 1 if Received By July 31 BILLING REMITTANCE' S REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE I DATE REMITTED AMOUNT FEELESS - PRORATION I I - - - 1J✓ PLUS PENALTY OTHER OTHER 4 0 Received by Date Receipt No Perm51 No�JJJ Issuance Date - "ed Delivered R = APPLICANT—RETLKALLCr"'ta TA: ENVIRONMENTAL HEALTH PERMIT/BERVICP,6��W7.HAZELTON AVE..P.O.Not 2009 _ STOCKTON.CA ft"ll W ii .