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Applications, Will 0 in Submitted Properly Completed. Be Sure To Sign The Application. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br />ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED, GIVE <br />APPLICANT'S AND/OR Make <br />CONTRACTOR AND/OR ENVIRONMENTAL HEALTH IT/SERVICES <br />BROKER AND/OR Lic. No. <br />LICENSE AND/OR iSM 1STABLUNIMENTS, HOUSING Regist. No <br />REGISTRATION - ATEIISAMIPLING g -- <br />NUMBER UAL ESTATE Color _ --- <br />POULTRY RANCHES AND KENNELS <br />r <br />MISCELLANEOUS 'SERVICES® r <br />FApplication Date Business/Nam To ppea On Permi r <br />a Type Permit/Service Requested: <br />r <br />Applicant Name Address - <br />_._ Busi If <br />ess Telephone No. Z `5� Emergency Telephone No. — <br />Property Location/AddressIlk <br />Property Owne Cu ` Address r _ <br />L Operator's Name` Address <br />1. FOOD ESTABLISH ENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br />RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br />FOOD PROCESSING PLANT ❑ sCOMMISSARY ❑ ICE PLANT ❑ BAKERY <br />.13 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 <br />3. WATER QUALITY 13WATER SAMPLE (Bacterial) a CHEMICAL <br />PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br />NO. OF PUBLIC SERVED (Connections) <br />a. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL D NATURAL BATHING PLACE <br />S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br />KENNEURun ys " /Animal Population No. No. of Confining Cages <br />wage `Disposal Method <br />Solid Waste Disposal Method <br />Water Supply Source ` Animal Waste Disposal Method <br />S. CONSULTATION FEE 021 ❑ BUSINESS LICENSE <br />7. :LAN CHECKING FEE'X, 13 DAN PERMIT <br />. REAL ESTATE <br />REQUEST: Water Well Inspection 0 Sample❑ Titieetompan <br />age ;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 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 1he San Joaquin L al Health D' trictL v <br />APPLICANT'S SIGNATURE Title , Date <br />FOR DEPARTMENT USE ONLY <br />Fee 18 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &'Received By January 31 ❑ July 1 & Received By July 31 <br />a <br />m <br />O <br />Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered 0 <br />R 0 <br />Y <br />(CANT—R TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE., P.O. Box STOCKTON,'CA 95201 W <br />BASE <br />EXPLANATION <br />BILLING <br />REMITTANCE*AMOUNT <br />$ <br />REMIT <br />DUE CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEE <br />r. <br />. a� <br />LESS <br />PRORATION' <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />a <br />m <br />O <br />Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered 0 <br />R 0 <br />Y <br />(CANT—R TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE., P.O. Box STOCKTON,'CA 95201 W <br />