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Tq _C1F(1-App*CaNWaMINI Be ""On 111ubwMtW ftep" �COMPIM■d.as sure To TWO AppYcabom <br /> �Jog+N <br /> SAN JOIAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> 9" ""L/°" <br /> A/PLlCAN"Al/ELrOR APPLICATION IF VEHICLE INVOLVED,GIVE C<W � " <br /> TTOR ANDMA ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br /> 0^011 I AN0101111 Lid, No. <br /> UCENN AMM311111 ION UTAMJRMM1INM MUM <br /> REnISTRAT" PMX PSK&■ATU SAMPIlea Regist. No. <br /> Mim"Pt REAL MATE IMs►KTMas Color <br /> -- I NKTRT RAMGIE!ads REMMELS �— <br /> MUM:tUAM OM tiE#rICER r /, <br /> fApplicalion Date _. ausinesa/Narns To Appear On Permit a, 7L. i fL�� _ ^� <br /> jType Permit/Service Request ylg/li���� C.� <br /> Applicant Nan-A !l—D8C6 LQQ7'OW Addretu 7 r <br /> —_— Business Tele hone No. — Emergency Telephone No. <br /> Properly Location/Addrsas r <br /> Property Owner T Address 4 .4 7 W4 d f,5,9 egkll, d T4'. ' r( i+ U 1Z f <br /> t Operator's Name Address - — <br /> 1. FOOD ESTASUSHMENTS Total Building Sq.Footage Restaurant,Maximum Seating Capadty <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 /> ❑ VENOING MACHINESR'b.of ❑ MOBILE FOOD PREP.UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTSWUNo.of Field Employees <br /> ALL APPLICANTS. Total Employees Induding Operators <br /> 2. HOtmNQ <br /> ❑ HOTEL/MOTEUNo.of Unft ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARKn4o,of Spoon <br /> S. WATER OUAUTY ❑ WATER SAMPLE(Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM 0 SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO.OF PUBLIC SERVED(Connections) <br /> t, RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds <br /> ❑ KENNEL/Rtxrwaye /Animal Population No. No.of Confining Cages <br /> Sawege Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> & ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. P PLAN CHECKING FEE t- ❑ DANCE PERMIT <br /> s REAL ESTATE 'k <br /> REQUEST: Water Well Inapecdon❑ Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <br /> Escrow No. <br /> Selig( Seller Address <br /> Teiephone No. Seiler Agent Name <br /> Service Request For Data <br /> I hereby certify that I have prepared this application and that the work will be dons In accordance with San Joaquin County <br /> ordinances,state laws,and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANTS SIGNATURE fJ TltieVa� !, L"t' p■te_v_�© f C�� <br /> FOR DEPARTMENT USE ONLY <br /> fFee Is DLO: ❑,ANNUALLY 0 PFR UNFT I' PER 64TE ❑ EACH _❑ J.,w«y I a R-0-0 a 9y.).- y St 0 July 1 a 31 <br /> REMIT <br /> BILLING REMITTAN(;L- y <br /> BASF EXPLANATION AM0i1NT pllF. CHEC'-7C® <br /> /DATE !`/--� DATE REMITTED A►*(TLRI'T <br /> FEE /+ �[z[ L.iJIv _. 12i 186 <br /> PR CM7 1004 �" f <br /> F11(is /1J �(�,� .R[/Yr• , <br /> Jv <br /> I'F NAI Tv : � low f ' VL1 <br /> DiHEH i <br /> - <br /> pTHFR ' <br /> cK / L�/'F�1 NI, I.a•,...r. [,.1. L.M+1 fl�l.n•.r1 _ <br /> ---- AfFT KAµT-11f TlµµAlLCI4RL�T0 fµv fµT AR µFlu fr+.l.Ylfrl/nvfCf� ,191[ µRift v!-.n ls• ]09i 0T1xK 11Y4,CA M{ <br /> h <br />