Laserfiche WebLink
rte, •.r� •.:,•� ' -'�.,. _ _ <br /> APPlIcatlons Will Be F�ssed When Sub nlfled Property Completed.Be Su i Sign The Application. <br /> SAN JOAQUIN` LOCAL HEALTH DISTRICT GENERAL <br /> II <br /> , . ENGINEER'S ANO/OR <br /> APPLICANT'S AND/OR APPLICATION IF VEHICLE INVOLVED,'GIVE 1 <br /> - <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT"/SERVICES Make <br /> BROKER AND/OR <br /> U0. No. <br /> LICENSE AND/OR FOOD ESTABUS HMENTS,HOUSING -- f <br /> REGISTRATION r� b[F b. - POILIC POOLS,WATER SAMPLING Regist, No. _ <br /> NUMBER f -t REAL ESTATE INSPECTIONS <br /> Color <br /> POULTNT RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES . <br /> i.rApplication Date /2--/(e a- Business/Name To Appear On Permit <br /> Type Permit/Service Requested:�cu��� <br /> A plican NameViA:l(YeY� �.�r� _. �i Address 20 <br /> Busines Tele Ocie No. 70 ZE! <br /> Emergency Telephone No. <br /> Property Location/Address — �U. sL <br /> Property Owner 0 <br /> Address-4-q— I_ Brr.l„p 3(0 <br /> L-Operator's Name t Address ,)< r i 45 <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. ootage, Restaurant.Maximum Seating Capacity. <br /> 13RESTAURANT 13FOOD MARKET RETAIL C3FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑-`ICE_PLANT ❑ BAKERY - E <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ -BAR ❑ ITINERANT RESTAURANT <br /> t.`❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑':FbOD 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 PARK/No.of Spaces <br /> 3. WATER[QUALITY ❑ WATER SAMPLE(Bacterial) Ia CHEMICAL <br /> '❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> ” NO.OF PUBLIC SERVED(Connections) <br /> ., 'I. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA. ❑.mADING.POOL 11NATURAL BATHING PLACE <br /> S. VECTOR CONTROL 13POULTRY FARM/Maximum NO:Of Birds I <br /> ❑ KENNEL/Runways /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> ,i Solid Waste Disposal Method fi <br /> Water Supply Source .Animal Waste Disposal Method <br /> S. 15 CONSULTATION FEE 5 s ll7A C ' / !' ❑ BUSINESS LICENSE <br /> T.. El PLAN CHECKING FEE ❑ DANCE PERMIT } <br /> a. REAL ESTATE <br /> i <br /> 'REQUEST: Water Well Inspection❑ Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tele.No. <br /> Escrow No. <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 /> x APPLICANT'S SIGNATURE Title ✓`! 1. _L: hDate ��+ 'I <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE' ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 A Received By July 31 <br /> BILLING REMITTANCE' s REMIT <br /> BASE E%PLANATION DATE DATE REMITTED AMOUNT DUE CHECKED { <br /> _( AMOUNT <br /> FEELESS <br /> �5✓. Q��" y/Z <br /> 6 � <br /> PRORATION /E� G , <br /> - <br /> ILI <br /> PLUS <br /> PENALTY <br /> E <br /> OTHER <br /> i <br /> OTHER _ m <br /> n" <br /> S _ XL- _�s�dab o <br /> Received by Date Receipt No. Permil No, Issuance Date Mailed Deltvered - <br /> APPLICANT—RETLIRKAL1.CODLERTo; ENVIRONMENTAL HEALTH PERMIT/SERVICER - 1601 E:HAZELTDN AVE,P.O.aea 100i 6TOCKTON,CA lu01 W 'I <br />