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Applications Will'Beunited Properly Completed.Be Sure ' Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTHDISTRICT GENERAL <br /> EN ETR'S AND/ORIF VEHICLE.INVOLVED,GIVE <br /> AP ICANT'S AND/OR i.l Ti Make -- <br /> CONTRACTOR AND/OR ENVIRONMENTAL., HEALTH PERMIT/SERVICES <br /> BROKER <br /> KER AND/OR` Lic. No. --- <br /> LAND/OR F ESTABLISHMENTS.ROUSING Reg st.;No. <br /> REGISTRATION PUNLIC LS,WATER SAMPLING --— <br /> NUMBER L ESTATE INSPECTIONS Color— -- <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> `Application Date 3°'�..� —858 _ Business/Name To Appear On Permit Construction OIIIpSTi� — <br /> Type Permit/Service Requested: ante QU Tank Removal — --- ---- —Applicant Name B & C (;C1T1Bt,T'=, DX LQ Sm Address 5633 8�'B�i� � SOC- 07 <br /> _ Business Telephone No. Emergency Telephone No.(2 ) 9 5 -9-304 <br /> Property Location/Address xAC 'V' * Tr cy, — <br /> I `Property Owner Shell i O�IT"STi� Address Cx` �21L0� �'ialifo is <br /> L Operator's Name Address <br /> I 1. -FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Seating Capacity <br /> RESTAURANT 13 FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> 13 FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ROADSIDE FOOD,STAND 13 LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> 13 CONFECTIONARY STORE 11 FOOD SALVAGER ❑ FOOD DEMONSTRATION" ❑ FOOD VENDOR <br /> 13 VENDING MACHINES/No.of ❑ MOBILE FOOD PREP.UNIT ❑ VENDING VEHICLE <br /> 13 FOOD CROP HARVESTING/No.of:Field Employees <br /> ALL APPLICANTS: Total Employees including Operators <br /> 2. HOUSING <br /> 13 HOTEL/MOTEL/No.of Units ❑ CERTIFICATE OF OCCUPANCY <br /> 13 MOBILE HOME PARK/No of Spaces <br /> 3. WATER QUALITY 13-WATER SAMPLE(Bacterial) 13 CHEMICAL <br /> 13 PUBLIC WATER SYSTEM 13 SURFACE WATER SUPPLY 11 WATER HAULER <br /> NO.OF PUBLIC SERVED(Connections) <br /> . RECREATIONAL HEALTH 0 SWIMMING POOL ❑ SPA 0 WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds <br /> KENNEL/Runways /Animal Population No. No.of Confining Cages <br /> 4 <br /> ----Sewage-Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> ti. CONSULTATI N FEE ❑ BUSINESS LICENSE <br /> 7. OPLAN CHECKING FEE ❑ DANCE PERMIT <br /> S. REAL ESTATE <br /> ;r REQUEST: Water Well Inspection E3 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 /> 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 /> APPLICANT'S SIGNATURE _Title Partner Date 3-11-8 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is 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 /> FEE e = ® �° <br /> LESS <br /> PRORATION p <br /> PLUS <br /> PENALTY G fr <br /> OTHER <br /> Y <br /> ro <br /> OTHER <br /> i <br /> o <br /> 0 <br /> Received by Date Aecp't No. Permit No. Issuance Mailed Delivered t <br /> APPLICANT—RET JELL TO: ENVIBO TAL HEALTH PERMIT/SERVICES 1809 E.HAZELT .,P.O.Box 1009 STOCKTON,CA 98101 <br /> W <br />