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� s <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 Bu aTne To Appea-r-0n_Fermit <br /> FType Permit/Service Requested: <br /> iAp Iicant Name 11A,(_6/✓j ✓ fl/ Address 37 C�A�IJ���� G�/*�/� �C%���i <br /> s�r�� Business Telephone No.�3— G�/cz_08� Emergency Telephone No. <br /> i Property Location/Address Jcc�h'N�3yy.� 604 — �-5 ��0 <br /> Property Owner ll Wi Address ____ /g���G✓ <br /> I 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 ❑ 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 14 <br /> 2. HOUSING -� <br /> ❑ HOTEL/MOTEUNo. of Units ❑ CER OF OCCUPANCY /P (,b //ff <br /> 11 MOBILE HOME PARK/No. of Spaces . <br /> 3. WATER QUALITY ❑ WATEA-SAMPLE (Bacteri CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑�S11RF ATER SUPPLY ❑ WATER HAULER <br /> NO OF PUBLIC SERV(Connections) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE J <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 �G <br /> Water Supply Source Animal Waste Disposal Method <br /> 6. ❑ CONSULTATION FEE J ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE _ ❑ DANCE PERMIT <br /> 8. REAL ESTATE <br /> REQUEST Water Well Inspection Sa �] Title Company <br /> Sewage System Inspection ❑ —Address Tele. No. I <br /> Escrow No. <br /> Seller Seller Add � <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 jrulesAnd r9riations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X Title,/74 Date <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 /> BILLING REMITTANCE $ EAMOUNT <br /> REMIT <br /> BASE EXPLANATION DATE DATE REMITTED CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 17- <br /> 111--7 <br /> Received b -- o <br /> Y Date Receipt No. Permit No. Issuance Date Mailed Delivered = <br /> APPLICANT—R ETLIHN.ALL rroicc TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 w <br />