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Appa,cetloro YAM Be Proovwd When Submitted Properly Completed.N Sure r. Sign The Application, <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT GENERAL <br /> APPLICATION IF VEHICLE INVOLVED,GIVE <br /> CONTRACTOR AFIDOOR ENVIRONMENTAL HEALTH PERMIT/SERVICES Atake -- <br /> GROREA NQr011 LIC.No. <br /> LICENW AF4VR FSM ISTARl1111OMM uses" <br /> REGISTRATION PSM;PSRL(ISATER MIMIN& Rapist. NO. <br /> Pa11ADER am[{TATE NISM q Color <br /> PMLTn RAMOM AM 1teTSIE11 <br /> MAIC AASE/1M www <br /> FApplication D110 f Susiness/Nome To Appear On Permit F'Tr"I'TT'TYrc'r'It'c"vcT-$ , <br /> ,Type PermiVSsMq aglrests :��_�� _• - . �n r E�7r rtA/ <br /> Applicant Nacre I I r Address Lam. <br /> _rwinces Telephone No Emergency To hone No. <br /> Pr Location/Address - <br /> Prop"Owtr _ r� � � n / Address, <br /> L Operator _s Name — _ Address 1 u•-•,•"— <. �(/� _ <br /> t. FOOD ESTAEU M NTS Total Building Sq. Footage Roaauranl MauNnum Sesttr(q CapacllY <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIOLIOR 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/W.of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operatore <br /> 2 NOUSWQ �, L <br /> ❑ HOTEL/MOTEL/No.of Units ❑ CERTIFICATE OF OCCUPANCY m A G <br /> ❑ MOBILE HOME PARK/No.of SIneM �Z�a 2 <br /> S. WATER QUALITY ❑ WATER SAMPLE(Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY D WATER HAULER =4 O <br /> NO.OF PUBLIC SERVED(Connections) <br /> A. RECIIEATIOP[AL HEALTH ❑ SWIMMING POOL D SPA ❑ WADING POOL ❑ NATURAL BATHING PLAT' <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximurn No.of Birds <br /> ❑ KENNEL/Rur weye /Animal Population No. No.of Confining Cages <br /> Sewege Disposal Method <br /> Staid Waste D"t Method <br /> Water Supply Sours Animal Wasle Disposal Method <br /> IL ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> T. PLAN CHECKING FEE ❑ DANCE PERMIT <br /> R REAL ESTATE <br /> REQUEST: Weler Weillrspection❑ Sample❑ TRle Compuly <br /> Sewage System Inspection ❑ AddreM Tele.No. <br /> Escrow No. <br /> Seller Seller Address <br /> Telephone No. Seller Agent Name <br /> Service Request For Date <br /> I nor" centty that 1 111109 prepared this application and that the work will M done in accordance with San Joaquin County <br /> ordinances,state Laws.and rules anno regulations of the Son Joaquin Local Health Dgtrict <br /> APPLICANTS SIGNATURE X Title E�j r <br /> i <br /> „9•,• 1F Date <br /> •� FOR DEPARTMENT USE ONLY " <br /> Fes N Dueler 13. Y. ❑ PCR.uNITD►ER SITE .❑ EACH ❑ J.~y I a Rtcelwe.ey.RwRyry 111 D AAy i•awoo we M July at <br /> e1111NG REMITTANOE F RI <br /> DATE DATE REMITTED FT <br /> B,lSE E%PLANATgN AIADIJI'!T DUE C= <br /> _ AMOIMf <br /> FEE <br /> LESS <br /> PRORATION r. <br /> PLUS C r <br /> PENALTY Imo- C. <br /> OTHER <br /> OTHER <br /> AI 1 IM _ 7 <br /> D.I. mn <.f r <br /> I <br /> APPLICYRT-w[TURJLLrtluaTO: aF��wwEMTu 11[ALM nerrtnEevltts test II.tlAa,..,faRaYR.AQ s..awe 11TOC11TOrl Utaan <br />