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--- " A�McaYena Will N rya d When sub"W"'d IF 'perry Come"I*` p. Ewe Tr n TM APPak��^- <br /> L <br /> NERA <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GE <br /> E VlNICLt GE x V-urK <br /> APPLICATION Make <br /> A/►LA1Q'OEI ENVIRONMENTAL NEALT}1 pERMIT/SERVICES Lid No <br /> DR ANO'DR esDUM Regat. fdo <br /> e.'EiF Yroron rPill"rFMt�SAU?tbe cola - ---- <br /> U,,Aw"AIA'Da aIAL ESTan RIaF(CTw" <br /> REOaTRATgVI PeaRTNI sASCMs AN"el \ Y All <br /> Tn1,acn ___---_ _ —.__�-/_. _ EE000EAMMIS WelUs <br /> �2.7-3 V Bu.iras✓NarM To Appear On _- <br /> rApplicaliun Data�----— - <br /> !mTyPePermiVServiwRgrNaNd: .----- o i�_/\OAreu.�—��'----- <br /> S Emergency Telephone No. �— <br /> Appllcant Name yr— _Business TNeOho^e No <br /> E n <br /> Properly Lpcation/Addrsas AddreM —. <br /> i Property O«ner-- Address <br /> L OperatlNs Nada Rsatsumi,Maximum Setting CepacltY - <br /> Total Building S0.Footage ❑ MEAT MARKET <br /> t. FOOD ESTABUSHME 000 MARKET RETAIL ❑ FOOD MARKET WHOLESALE 13 BAKERY <br /> ❑ RESTAURANT COMMISSARY ❑ ICE PLANT <br /> C1 FOOD PROCESSING PLANT ❑ ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ ROADSIDE FOOD STAND ❑ LID"STORE 11 FOOD VENDOR <br /> ER ❑ FOOD DEM <br /> ❑ CONFECTIONARY STORE ❑ F000 SALVAGER <br /> ❑ VENDING VEHICLE <br /> ❑ ktOBILE FOOD PREP.UNIT <br /> ❑ VENDING MACHINES,No-Of <br /> ❑ FOOD CROP HARVIESTING/No.of Field EJnpIDYsss <br /> ALL APPLICANTS: Total EJTEployeea Indudang Oparslon <br /> I HOUSING ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ HOTELMOTELMo.Of Unb <br /> C3 MOBILE HOME PARK/ND.Of Spews ❑ CHEMICAL <br /> 7- WATER QUALITY ❑ WATER SAMPLE (Bacterial) <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO.OF PUBLIC SERVED(COnnectiODs) ❑ NATURAL BATHING PLACE <br /> e. AECpFATIONAL HEALTH [I SWIMMING POOL 13 SPA C3 WADING POOL <br /> S. VECTOR CONTROL ❑ POULTRY FARMMasimurn No. Of Birds <br /> ❑ KENNELR1Rtweys <br /> /Animal Population No. No.of Confining Cagr <br /> Sewage Disposal Method <br /> Solid Waste Onoosal MsVod <br /> Walter Supply Sou. Mittal Waste Disposal Method <br /> s. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> T. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> L REAL ESTATE <br /> REQUEST: Watar Wall Inspection❑ SampN❑ TRIe Company <br /> Sewage System Inspegbn ❑ Address Tele. No. <br /> Escrow No. <br /> Seller Seller Address <br /> Telephone No, Seller Agent Name <br /> Service Request For Dal, <br /> ,I hereby cartify that 1 nave prepared this application and that the work will he done in accordance with San Joaquin County <br /> ondinences. state laws.and tulsa and regulations of the San Jwqum Local Health District. <br /> APPLICANT'S SIGNATURE X Title _ Dam .__-___-__ <br /> I FOR DEPARTMENT USE ONLY <br /> Fee la Dtle:❑ ANMIKLy ❑PER UmT ❑ PER TJn ❑ EACH ❑ Jww.y t a P M JeNMry It ❑Jury t a Rrwww er JNy tt <br /> REMIT <br /> elaltrO REMITTANCES <br /> DASE EXPLANATION AMOUNT WE CHEK1 ff <br /> DATE DATE REMrtTED AMOIAn <br /> EEE - o'- _r4!/�Q. u415 ! D✓ 'V <br /> LESS <br /> AiORATiDN _ I <br /> P(N <br /> OTT.ER <br /> OTHER HERRTMIR <br /> RNH�wI e/. pHA Nw Npl Ne Y�.�1 Nn I��wY�ISH WSW rM.w.�t <br /> a11lKYrT�e(TUaN LLLCNMafO rNVMOYYrNtY Nr1\IM...YO/1f NwC[• 1YIr NAIf\rON•�l_10 a� iA •TOCa1(YLU YIer <br />