Laserfiche WebLink
ApplIC41rtaVna wir vr,- <br /> " N JOAOUIN LOCAL HEALTH DIST-'CT GENERAL <br /> ENGINEER'S AND/OR APPLICATION lF,,VEHICLE INVOLVED.GIVE <br /> APPLICANT'S ANO/ORMake -- <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH.PERMIT/SERVICES Lic- No. -- <br /> BROKER AND/OR FOOD ESTABLIStIMENT&-HOUSINC <br /> LICENSE ANO/OR PUSLIC POOLS.MATER SAMPLING Regist. Na. <br /> REGISTRATION HEAL ESTATE INSPECTIONS Color <br /> NUMBER POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> FApplication Date Business/Nari,e To Appear-0n Permit _ <br /> .Type Permit/Service Requested: — <br /> i Applicant Name �l Address <br /> o _ Business Telephone No. Emergency Telephone No. <br /> ILProperty Location/Address <br /> iProperty Owner Address <br /> L Operator's Name Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage " Restaurant.Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD NIARKET,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 /> ❑ HOTEL/MOTEL/No. of Units 13 CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces <br /> 3. WATER OUALITY ❑ 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 <br /> 5. 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 a– <br /> Water Supply Source Animal Waste Disposal Method <br /> a. ❑ CONSULTATION FEE ❑' BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> a. REAL ESTATE <br /> REQUEST: Water WeiI Inspection 13 Sample 12 Title Company <br /> Sewage System Inspection ❑ Address , Tele- No. <br /> NO. <br /> V r^. <br /> Seller <br /> 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 District. <br /> I. APPLICANTS SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 d Received By January 31 ❑ July 1 a Received By July 31 <br /> 1 7,1 REMIT <br /> BASE EXPLANATION I BILLING REMITTANCE' S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS _ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER I <br /> - Y <br /> OTHER <br /> n <br /> 0 <br /> 0 <br /> Received by Dass Receipt No. Pelma No.� � IS.7uanCe Date Mailed Delivered <br /> 2009 3TOCKTON,CA"201I <br /> APPLICAIIT—RETLLaftALLC&W=S.TO: ENVt8ONa6ENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.C.Sea <br />