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1 111111117 <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR <br /> APPLICANT'S AND/OR APPLICATION IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make. <br /> BROKER AND/OR Lic. No. -- __— <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> REGISTRATION PUBLIC POOLS,WATER SAMPLING Regist. No. <br /> NUMBER REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> [Application Date Business/Name TckAppvar On Permit <br /> v,Type Permit/Service Requested. 1 � y <br /> uApplicant Name L1 J t.1� Address wj�� �j � C 'rte V1nl�v1- c 11°r <br /> 4 --- ___ Business Telephone No. Emergency Telephone No. — <br /> �Property Location/Address L,���/y►1��L -t `sem t/Yl AAddress <br /> j PropgrL�':�`� S..h1.�yY1 = `� <br /> Operator's N�mer 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 ❑ 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 ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) <br /> 0. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> ❑ KENNEURunways /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source _ Animal Waste Disposal Method <br /> B. 3�,,,,CONSULTATION FEE *5,, ❑ BUSINESS LICENSE <br /> 7. .h PLAN CHECKING FEE4 ��_ _ _ _ _ ❑ DANCE PERMIT <br /> B. REAL ESTATE <br /> REQUEST Water Well Inspection 11 Sample Title Company <br /> Sewage System Inspection ❑ Address _ _ Tele. No. <br /> Escrow No. <br /> Seller Seller Address <br /> Telephone No. <br /> 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, an I and re ation - e n Joaquin Local Health District. <br /> 4,/- <br /> yl j G � <br /> APPLICANT'S SIGNATUR Title 4,/-'e, Date /d /� o S <br /> FOR DEPARTMENT USE ONLY <br /> Fee 19 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE' $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE11,0 1 <br /> ✓— v U <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> 4, <br /> OTHER <br /> a <br /> OTHER <br /> e <br /> O <br /> Recei y Date Receipt No P it No Issuance Date Mailed Delivered <br /> 2 <br /> - <br /> APPLICANT—RETIICH AI-L COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 w <br />