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Applications Wv'Qe ProcessedWhenSubmltteaPlaperry160mpl91.o av,v ,....,y.. ... i <br /> V JOAQUIN LOCAL HEALTH DIS " T GEIVEIZL <br /> ,� IF VEHICLE INVOLVED,GIVE <br /> ENGINEER'S AND/OR APPLICATION <br /> APPLICANT'S AND/OR : Make -- <br /> CONTRACTOR AND/OR —p ENVIRONMENTAL HEALTH PERMIT/SERVICES tic. No. — <br /> BROKER AND/OR I;' <br /> LICENSE AND/OR i00d ESTARLLSIIIEENTS.IIdUSU1G RegiSt. No- <br /> REGISTRATION MIlLIG re"WATERiAM►L1MK ' <br /> NUMBER REAL ESTATE I"PECTIOIIS Color <br /> POULTRT RARCNEE AKO KINNELS <br /> Rt1SCELLASIOUS SERVICES ��•��✓ rY 7,�' .� <br /> FApplication Date ��• �, Business/Name To Apr On Permit — - <br /> ,aType Permit/Service Requested: ' ` ` .�r. �`'"'� - '"'yr�' _ <br /> z.Applicant Name Address •F r - F - - - <br /> - Business Telephone No.. T '7 7 Emergency Telephone No. - - — <br /> �Property Location/Address <br /> a Property Owner `�+- - '.9 " Address <br /> Operator's Name '�#-` Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage I: 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 <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING <br /> ❑ HOTEUMOTEUNo. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces ja <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL, <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO.OF PUBLIC SERVED (Connections) <br /> <. 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 Dirrosal Method <br /> Water Supply Source Animal:Waste Disposal Method <br /> 6. ❑.CONSULTATION FEE - - - "-^ ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> a. REAL ESTATE <br /> RECIUEST: Water Well Inspection 13 Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <br /> Escrow No. y: �� <br /> Seller Seller Address <br /> Telephone No. Seller Agent Name <br /> Service Request For Date <br /> 1 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 District. <br /> APPLICANTS SIGNATURE x Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July I a Received By July 31 <br />' REMIT <br /> BILLING REMITTANCE' f <br /> BASE EXPLANATIONBILLING <br /> DATE REMITTED AMOUNT DUE CHECKED <br /> k <br /> AMOUNT <br /> FEE 'r <br /> LESS <br /> f PRORATION f <br /> PLUS <br /> PENALTY <br /> f <br /> OTHER <br /> f - <br /> OTHER <br /> r. <br /> o <br /> Recewed by Date Receipt No. Permit No. _ Issuance Date Mailed Delivered <br /> I <br /> APPLICArrT—RETLtY11JUJLCOa'JEi t&. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1401 E.HAZELTON AVE.,P.O.ass 206 STOCxTON.CA Ssmi W <br />