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AppNCWpr WM Se anuas When sub irlad PreParfy Compr•1rRL M luny,tion The AppY,.0 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> E'[Oe"'ff AMO OR APPLICATION IF VEHICLE INVOLVED.GIVE <br /> APPLICANT?AfrD'OR <br /> COMTRAGTOR Aw'DR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make -- <br /> aROREA AIbVR <br /> Lid. No. <br /> ll(:ErgE AND/011 IRM EaTAalIaMMM1.MYa1M <br /> REOIHTIUTgti HIMIC FMA MATO UNPUM Regist. No <br /> M1Ms . <br /> NUMBER CL S p t t� REAL ESTATE I /KiColo[ <br /> r PatKTIRT asM OU AM AEMLLf <br /> _ MMMLAMMM M1MQf �f p <br /> FApplication Data Busin Name To Appear On Permit �yLtd,C /f(m SZaww g Co4me /1 S <br /> .Type PermivZo ice Request :_ � ✓/�' _ <br /> Applkant Name C ?AlC• TJZGr Address zmCzv<-=A . <br /> _ Business Telephone Emergency Telephone No.Z1 —JZfW <br /> Property Loution/Addre�+ _L ST G <br /> 4PTeeartyOwn« .TG><7 4S6A Address 5,777 �M►yscn /�!� �' v30 t/pJNjp <br /> L Operator .Q <br /> Operators Name�}�fM( &A 1( ix �o Address 617" F �Z&A B/ae, L C/ _ <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage RestouranL M"Imum 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.M Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2 HOUSING <br /> ❑ HOTEL/MOTEUNo.of Unit ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spectra <br /> 1 WATER OUAUTY ❑ WATER SAMPLE(Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED(Connections) <br /> s. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Masimum No.of Birds <br /> ❑ KENNEL/Runways /Animal Population No. No.of Confining Capes <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> S, ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. PLAN CHECKING FEE _ 13 DANCE PERMIT <br /> L REAL ESTATE <br /> REQUEST: Water Well lrrpectlon❑ 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 Dole <br /> 1 hen sby certify that I have=FOR <br /> that Me work will be done in accordance with San Joaquin County <br /> ordinances,state laws.and n Joaquin Local Health District. �J <br /> APPLICANT'S SIGNATU XTill Date <br /> RTMENT USE ONLY <br /> Fee b Dee:❑-ANMIALLY ❑PER UNIT 0 M S TE ❑ EACH ❑ Jwwany 1 A RaLWwe 9y JYwry]I ❑ Jury!A R.cw.N or Jply JI <br /> REMIT <br /> BASE EXPLANATION RILLIHO REMITTANCE s AMOUNT DUE fiTEC6ID <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> MORATIDI! <br /> PENALTY <br /> OTHER } - - <br /> OTHER <br /> - <br /> �M'bel' M� Rw�.plM i•.—1 Mn IUW K•�N WNA D�1n.w�A <br /> AM ICUIT-II(TOYN A[y f11ILL•t0 [MVMONM[NI AI MI AITN[[nasi!rt[nvlC[r IFpI f.NAL[ITOM AY[_10 MLA aTO�XTOIL CA[Ar[ <br />