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1Z. APo,ue„""e•ww sa�.a wth.n el,eeww Propertycamw«w. be wee Te �1 The App4Caflen, <br /> SAN JOAQUIN LOCAL HEALTH DISTA GENERAL <br /> UedINLEra Amro^ APPLICATION IF VEHICLE INVOLVED,GIVE <br /> C0 TQM +Dwarf ENVIRONMENTAL HEALTH PERMIT/SERVICES Make -- ' <br /> enoE[Er ANO/OA <br /> Lid. No. _ <br /> UCENU AMOIOR IeM L7►MweYlfft,Ilellerrre Regial. No. <br /> ReolsrRAThoN FYeEK FML.MATO UNIM)N <br /> ILM IATARI M k-ECIVH Color <br /> - -7 FMKTRT EANCf[L AM RIM US ( _ <br /> ■ISCOlASKeW MaeECL /«/ <br /> r Appllutlon Oate 1,( 0--_ Business/Narne To Appear On Permit 15-7L <br /> .Type ParmlVServic Requested _lis r�� f LUT rI� <br /> Applicant Name__ �� -,'T�Tlli�7 _ — Address / �✓ 1 <br /> Businesselephone No. Z— 4ll Emergency Telephone No. <br /> Prop"Locatic, ddreas ( � '` LJVLu M, <br /> Property Oen« t(1-11 5 zbca / 2 AcidreM `sem! rfyrJu, D, �iTL'l( r <br /> I Openlols Name <br /> (MA 0"15!S Address K <br /> /. FOOD ESTABLISHMENTS Total Building Sq. Footage Reataursnl Masimum Seeding GPadtY <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> O 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 Fire pbye re <br /> ALL APPLICANTS: TotalErep[oyeM Indudirg Operation <br /> 1 HOUSING <br /> ❑ HOTEL/MOTEL/No.of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARKINO.of Spates <br /> 1 WATER OUALITY ❑ WATER SAMPLE (Bacterial) - ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO.OF PUBLIC SERVED(Connections) , <br /> e. 11ECftEAT10NAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Makimum No.of Birds <br /> ❑ KENNF]JREMweys <br /> /Animal Populaliorl No. No.of Confining C" <br /> Sewage Disposal Method <br /> Slid Waste DispWAI Method <br /> Water Supply Anknal Wsate Disposal Method <br /> S. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> T. P-PUN CHECKING FEE 1-1r''T C409111?-€ ❑ DANCE PERMIT <br /> s, RM ESTATE <br /> REQUEST: Wstar WNl inspection❑ Safnple❑ Tllie Company <br /> Sewage System Irnpedlerh ❑ Addresa Tele.No. <br /> Escrow No, <br /> Seller Seller Address <br /> Telephone No. Seiler Agent Name <br /> Service Request For Date <br /> 1 hamtry certify that I have prepared this application and that the work will be dove, In accordance with San Joaquin County <br /> ordinances, lisle laws, and rubs and <br /> regulations of the San Joaquin Local Healih District. <br /> APPLICANT'S SIGNATURE x_ G/r�liYJ —. Title � ' f-' -' ate <br /> FOR DEPARTMENT USE ONLY <br /> FN Is Due: O ANNf1Kl♦ ❑"R UNIT ❑ KP 61TE D EACH ❑ J....a Y 1 A R�cMwJ BY Jrw•v)h J.h r A fhrw..0 9'I J••h]I <br /> I --- RCUIT <br /> RAS[ ErFI ANATION nILLINq RfMITTAN(:E 1 AypUNi Dl1E CNfGIm <br /> OAT E PATE REMITTED AYIXMT <br /> FEE <br /> SUS <br /> 1(HI.I fY - <br /> 4 <br /> OIHPR_ <br /> •IRK..••-nlTlllw ul fnAUI.O Iv"vNRrlMr.t MI.l1..........wrK.Ir �V�I nAf1\IOn.rT. •n Y• Y1M •.00RInK CA e,en <br />