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�yr+esne Will Se 11 rd ulher {VbNllitee Pr+Perh' Cemple•ee. N it,To <br /> GENERAL <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> IF VEHICLE INVOLVED,DIY! <br /> APPLICATION Make--� <br /> HALT}{ PERMIT/SERVICES Lid.NO <br /> „morOetµ� ENVIRONMENTAL Reglet. No - <br /> oA AlfWOaEIDTE.PWJS" <br /> ,AOI OR AEIWI I=NK WETER YrFUM CW« __ - -- <br /> fte AIID'Oq <br /> AlOeTMTION rVATEll AIICM AM El's <br /> lARASER — _ — omMLAMWE MEYtCU <br /> Busnese/Narne To APPEu On Permit <br /> Application Dere <br /> .Type Pe\mlVSartin Requested' .-�,- /lNl.�/L� Address /-- — - a TNEDIEDm No, <br /> Appiicenl Norte Emergency <br /> BDefMY TellphOne <br /> Progeny Local-XVAddree <br /> Pmpany owner A rens <br /> L OPeraloYa Name RetaUn t.Maximum Sealing Capady N <br /> 1. FOOD ESTABLISHMENTS Total Building S0. F tag* <br /> 13MEAT MARKET ' <br /> 13 RESTAURANT 13 FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ BAKERY <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY C1 ICE PLANT <br /> ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ ROADSIDE F000 STAND. 11 FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER <br /> ❑ VENDING MACHINES/reo,of ❑ MOBILE FOOD PREP.UNIT 0 VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTIWUNO.M Field Employees C`(/�M" <br /> ALL APPLICANTS: Total Empbyeea Including Operators P ,� ��//�F�///�/ <br /> 2 HOUSING ��([�(„ / / <br /> ❑ HOTEL/MOTEL/No"of Units C1CERTIFICATE OF OCCUPANCY 6WATERU� <br /> ❑ MOBILE HOME PARK/No.of Spans / v I% (J <br /> 1 WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL q f <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO.OF PUBLIC SERVED(Corrections) / <br /> e. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds <br /> ❑ KENNEI.Munways /Animal Population No, No.M Confining Cape <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Sours Animal Waste Disposal Method <br /> IL ❑ CONSULTATION FFA ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> 1. REAL ESTATE <br /> REQUEST. Water WNI Inspection❑ Sample❑ Thio Company <br /> Sewage System Inspection ❑ Acidness Tole. No. <br /> Escrow No. <br /> Seller _ Seiler Address <br /> Telephone No. _ Seller Agent Name _ <br /> Service Realest For Date <br /> I hereby osrtlfy that I haw prepared this application and that the work will be dee in accordance with San Joaquin y <br /> ordinances. rats laws, and rubs aro regulations o a San Joaquin I�peai ea th oVfjKt. �^ � ®i /1Ch �6Z <br /> �'I II_`'6 haps (Tl Sip ITOr T/���• <br /> APPLICANTS SIGNATURE X Title Dale <br /> FOR DEPARTMENT USE ONLY <br /> FM Is D1e' ❑ ANNUALLY 0 MR UNIT 0 PEA NYE 0 EACH ❑ JenIIwI,I a 11aNM eF Jrxry T �❑JWy\a 11Kw.M B\ ")r <br /> REMIT <br /> BASE EXPLANATION EILIIMp REMITTANCE / AMOUNT pEIE O•ECIrm <br /> PATE�V/ DATE REMITTED ABMT <br /> I�Ei <br /> EEE <br /> EE53 <br /> Pq(MAl IDN 1 <br /> ave <br /> rf NAI Tr <br /> OTHER <br /> OTNPR <br /> ...«..n M _ -._ _ INa ww.•p uP L...n Nn hlw..•Toss u..Ne TIr+wM -.__ � <br /> LLLCpAY\t0 IMYMOMYfMtLL Nf A\rat lt.vIr11wVCtf I.pl/ NAIlIfON Avf10 MOO! •\OCet(YL CA ItI.\ <br />