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_ Ay <br /> AOWIeeYpr Wal be P-0 Wher1 sub in"►roper&, Cempletac be teMre To The Appaca&lon. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> Daou[us AN1DfOA APPLICATION IF VEHICLE INVOLVED,DIVE <br /> cart?�ACTORANoroA ENVIRONMENTAL HEALTH PERMIT/SERVICES &'Aske <br /> OAOKM AKVIO 1 Lb. No. <br /> LICENSE ANDIOA - IaeS ESfAalYS1111ETS,MSYSM <br /> nsOlsnuTloN PM X Peds,WARS SANPU" Regia&.No. <br /> &wJsreEll UK ISTATE IMs►ECIHM Color <br /> -- Pe1Kla/SAMCM S AM"EMIL" <br /> MNCDEAMISM EUWCU <br /> [Application Date_ ! l Sp _77B----uf,ines��s/�JN�,�fE1mrer��T�xo}}��Ap{p��iat�O,e�nI Permit <br /> Ie Type PermlVSerrice�Reguested: . i-V� .�rr�-V rT �_r <br /> Applicant Name_�I Z"I _�r�l2l�( V`"1�6—19-- rC AOoreu`i�i 5`� . torn&,4T -A, <br /> 7 7 Bua nese Telephone No. Emergency Telephone No. <br /> Property Location/Address T.Ats-�ASC-,q <br /> 4Propterty Owner�1///}}}cccJJJ� Al�i'C21PCh'ru/� Adorer C c <br /> I Operator's Name-� Address V ~ <br /> 1. FOOD ESTASLISHMEIM Total Building Sq. Footage Restaurant Maximum SeaWq capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND. ❑ LIOUOR 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.of Field Employses <br /> ALL APPLICANTS: Total Empbyess Inducting Operators <br /> 2 HOUSING <br /> ❑ HOTEL/MOTEL/No.of Unb ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces <br /> S. WATER QUALITY ❑ WATER SAMPLE(Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO.OF PUBLIC SERVED(Connections) <br /> e. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM(Ma timum No.of Birds <br /> ❑ KENNEL/Rurtweys /Animal POpulet on NO. No.a Confining Capes <br /> Sewage Disposal Method <br /> Said Wane Disposal MtepgO <br /> Walter Supply Spume Ankr al Wine Disposal Method <br /> IL ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> T. �L PLAN CHECKING FEE J—U5T MDI) A/ ❑ DANCE PERMIT <br /> S. REAL ESTATE <br /> REQUEST: Wetter Well Inspection❑ Sampla❑ Title Comparry <br /> so""System Inspection ❑ Address Tele.No. <br /> Escrow No, <br /> Seller Sailer Address _ <br /> Telephone No. Seller Agent Name _ <br /> Service Request For Dais - -- <br /> ,I hereby nsrtlty, that I have prepared this applicationInd that the work will be dons in accordance with Sten Joaquin County <br /> ordinances,state la nd rubs and regulations t San Joaquin Local Health District. <br /> o _ ri <br /> APPLICANT'S SIGNATURE G Title <br /> Y — <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:❑ ANNUALLY ❑PER UNIT ❑ P!F SITE ❑ EACJI ❑ Jw t e A..o.N+1 eYJArw..rl')1 ❑JuN I by A.n 31 <br /> r- ------ - - . ._. ------- REMIT <br /> BILLING REMITTAr :,- t <br /> f1A5E EIIIl AN ATIDM DATE DME r, REurtIE(r A. LFNI DEIF GRECRID <br /> AM(%MT <br /> EE (4"77 <br /> ,Ess <br /> vr+<ww r Irxl I ; <br /> I,DS <br /> PFNAI ry t �IPLA�-(C4 <br /> 01,11. <br /> DrNeq <br /> . +m,c..rT +r r,lA..u�uvua ro rr.v,.o..reaul ..r+n�.r+..r. .r..,cn rw,r ,.uelro....e,ro v. ow •rr>cArrw.,u rJr1 <br />