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ArVMeellan WN M 1 hen WtfrawM"RroM[h C—"0049&M sufe Te '• The AppMcaMen- <br /> G SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> mamod "Amo+o++ APPLICATION Is vEHK�E tlfvoLtrE�'fasrt <br /> Mak. <br /> a+t ANDOOR ENVIRONMENTAL HEALTH PERM T/SERVICES Lid.No. -- <br /> MOKER ANWOR IME V""Ummor .now" Regial. No. <br /> UCCMK AMWOR PMIJC ps"wam EAwtm <br /> PWGJST14ATOON YY umitl mirmnew Color <br /> mpAmri F KIN#ANCOM AM RUNHLE <br /> WISCOIANOW EMtI M <br /> fAppllcation Dau 9-18-86 Businesa/NmInw To Appew On PWWA <br /> iTpfop" <br /> fp*P„mn Service Requested: obies 7-11StoreAP010i1Name Christo her Hollowe Addrem� E1 Stnrktnn; Q57Q2Business Telephone No. Emergency TelephoneNO. <br /> LocatiofVAddress 9110 Thornton Rd. , Stockton <br /> I pmp"Ow'1W Address <br /> L Opa[atOrf Name Addro" <br /> 1. F000 ESTADUSHMENTS Total Building Sq.Footage Aaalau ALEwvt MexMrttrm MEATSeatincap"" <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WWXESALE ❑ MEAT MARY <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ ITINERANT <br /> ❑ ROADSIDE FOOD STAND. ❑ LIOUGR STORE ❑ BAR ❑ 1TINEAANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDlfq MACHINES/No Of O MOf31LE FOOD PREP.UNIT ❑ VENDING VEHKXE <br /> ❑ FOOD CROP HARVESTWO/N&of Field EftrWYMs� <br /> ALL APPLICANTS: Tolal EnWWYeM M+dudirq OP@mk" <br /> 3. HOUSING <br /> ❑ HOTEL/MOTE JH&of Unft E] CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PAAX/N M of Spews <br /> i WATER QUALfTY ❑ WATER SAMPLE(Bectsdal) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY 17 WATER HAULER <br /> NO.OF PUBLIC SERVED(Connect orml <br /> 4. RECREATIONAL HEALTH ❑-SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> IL VECTOR CONTROL ❑ POULTRY FARM/M0XWi wn NO.Of Bkda <br /> m❑'KF1fftEL/RtarlwY� /ASI PopWatlon Na. ' _ No.of ConfNtMlg Cages <br /> Sew"Disposal Method <br /> Solid Waste D"Medwd <br /> WSW Supply Soutom Anhvm i Walla Dlapo$M Method <br /> S. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> T. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> IL HEAL ESTATE <br /> REOUEST: Wow Wed krpscti- 13 Bampw(3 Tills CornPWVq <br /> Sewage Syabm kAPK*M ❑ Add"" Tela.No. <br /> Escrow No, <br /> Sella( Seller Addraae <br /> Telephone No. Seller Agent Name <br /> I <br /> Service Request For Date s <br /> I hereby earthy that I have prepared this sWicailon and Mat the work will be dorm in accordance with Sen Josquin County <br /> ordinances,state Laws.and rules and regulation"of a San Joaquin Local Health Disirlct. <br /> - L <br /> J,4 <br /> APPLICJIrYT S 51GNATURE X - Tltle Date <br /> FOR DEPARTMENT USE ONLY <br /> I Fee Is Dw: O•AfwauAtEr ❑r[a tnwr ❑ rt►(sfrE ❑ Fwca+ ❑ J.rrfrT+►R.o.1.f4 EN AWW++v.s+ ❑ .h.N 1 aEul h+►r n <br /> (LASE EKKAHATI0N BILLING REMITTANCE 1 AMOUNT Oil(: C►fECfCED <br /> DATE GATE pE MITi(U AAIOIMT <br /> ,f( $10,00. @$10, hr. - 5earch review & (opy <br /> L f SS <br /> PH(HIATI(?ff_ <br /> 1.1115 <br /> 1.0 <br /> /1 4.40 44 cop1 es - ---- _--_- <br /> oTl.f•N 1.58 Postage i $15.98 j. <br /> e <br /> pec�r wl W ILI• Hw. ..0 <br /> t <br /> \►rt.0 1wT—\f rLa AJLC+NJ1•f0 f,rvW0f 0MTp4 .ff Atf•.f•f 1...7.\f f1+TC[1 IY1[ MAlf%IO..AVf PO M. 10G1 110c"OK C-A 1 1 a <br />