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Applications Will Ba f'~ NRlan Submitted Property Comptrtad, Be Scn The ApplicaSlorL <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEERS ANDIOR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANTS <br /> o <br /> CONTRACTOR I ENVIRONMENTAL HEALTH PERMIT/SERVICES �k o <br /> BA04CER AND/OR <br /> LICENSE ANOVOR FOOD ESTisusmm UTs.HOUSINS Regist.No. <br /> REGISTRATION PUSLIC POOLIL WATER SAINPUNG <br /> NUMBER MEAL ESTATE IRSPETtORS Color <br /> mLTai ItAMGKES AND KENNELS <br /> A- <br /> miscELUNEOUS SERVICES <br /> fApplicallon Date 1 b Coo Business/Name To Appear On Permit <br /> jType Permit/Service Requested: &51A <br /> Applicant Name `�Ad��drCCel�ss�� <br /> Business Telephone NaEmergency Telephone halo. <br /> Property Location/Ad rens <br /> iProperty Owner L 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 MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ SCE 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 /> ❑ HOTEUMOTEL/No,of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK1No.of Spaces <br /> 1 NEATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY 0 WATER HAULER <br /> NO.OF PUBLIC SERVED(Connections) <br /> '4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE r <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 Disoosal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> S ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> T. Pr PLAN CHECKING FEE _ &g-2 —❑ DANCE PERMIT <br /> R REAL ESTATE <br /> REOUEST: Water Well inspection❑ Sample[3 Title Company <br /> Sewage System Inspection ❑ Address Tele.No. <br /> Escrow Na. <br /> Seller Seller Address <br /> Telephone No. Seller Agent Name <br /> i <br /> Service Request For Date <br /> I hereby certify that 1 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 5}GNATU Title Date '" <br /> FOR DEPARTMENT USE ONLY <br /> Fae Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 6 Received By January 31 0M 1 i Received By JOY 31 s <br /> RELIT <br /> EXPLANATION BILLING REMITTANCE' : ALOUNT DUE CHECKED <br /> BASE <br /> 77IGATE DAT I <br /> /E Q� REMITTED ALT <br /> FEE !fC1Cl�t� F✓ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER �. <br /> r <br /> OTHEh <br /> 14 !o-(v -bio j y3gZ <br /> _ o <br /> 0 <br /> Recti ved by Date Romp%No" Penna No. Issuance Data tailed Delivered F <br /> APPLICLILT—RETuaxALLC4P-ws TQ EM1nBOHNEWAL HEALTH PEl UMSERVICES 1601 1-HAZELTON AVF-P.O."—ZM STOCKTON.CA SSW Y <br /> t <br />