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ts+oe+nRm ANOlolt <br />APPLr—# fM AIOIOR <br />CONTRACTOR A OMA <br />MIOKIR ANOIOR <br />11COM! ANWOR <br />ftGOSTRAi W44 <br />NLPAKR <br />Apolleeeofu WNI M a1.Mnitted 1 CefrlWete< M a..fe To Ahlicatlwn. <br />SAN JOAOU1N LOCAL HEALTH DISTRICT <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />GENERAL <br />IF VEHICLE INVOLVEO. Ora <br />Make <br />Lid. No. <br />TOM MAKA011MMIX 11101181011 Regist. No. -- <br />P"M MMA VATttS /A11/UM <br />mAi 9"An MtOMCT1MF Color <br />"wily 11ANCws AM Roll u <br />1lacawtewlt intAas �Ei2T7 F/� <br />�jQpt:.t'�' u/G GO L/F <br />rAppliuti«► Date 9/?,9/6(0 Bwiness/Nm* To Appear On Pttrrrt% <br />4 <br />A0JNT DUE <br />Type Per 1WService Re.QYes A% <br />ApptlCaht"name G. ia. Lt�oM __ �Q�, //�/G. Addr - J <br />09 <br />WSW <br />S!Slai_ Business Telephone Al <br />Emergency Telephone No.Z� <br />Property LOcation/Address <br />Property Owner h LAM hjh, Addrees <br />— I <br />I OWratoes Noma Cram Q-6 c2a.0C.Q-S Address Ilio W Pic CQL1 ate_ _IG�e�a. LA <br />t. F000 ESTASLISHMENTS Total Building Sq. Footage ReeteurarwL MaxMnum 8oatkq Capacity 9' toe <br />❑ RESTAURANT ❑ FOOO MARKET RETAIL ❑ FOOD MARKET WHOLESALE <br />❑ MEAT MARKET <br />O FOOD PROCESSING PLANT O COMMISSARY O ICE PLANT <br />❑ BAKERY <br />❑ ROADSIDE FOOD STAND. O LIOUOR STORE O BAR <br />❑ ITINERANT RESTAURANT <br />O CONFECTIONARY STORE O FOOD SALVAGER O FOOD DEMONSTRATION <br />❑ FOOD VENDOR <br />O VENDING MACHINES/No. of O MOGILE FOOD PREP. UNIT <br />O VENDING VEHICLE <br />❑ FOOD CROP HAIWESTIWL94M of Field Emploreee <br />ALL APPLICANTS: Total EntptayoM M+dudln9 Operatore <br />Q Am <br />f� V I L.O 1 a ' 4. ' 1T <br />i H011ftNO O CERTIFICATE OF OCCUPANCY 1440. `E, 29 17 <br />O HOTEL/MOTEL/No. d u1w <br />O MOBILE HOME PARK/Nm I- �r+ecce <br />S. WATER QUALITY O WATER SAMPLE (Bacterial) O CHEMICAL <br />❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY O WATER HAULER <br />NO, OF PUBLIC SERVED (COnnectkxn) <br />4. RECREATIONAL HEALTH O SWtMMtNG POOL ❑ SPA O WADING POOL O NATURAL BATHING PLACE <br />>L VECTOR CONTROL ❑ POULTRY FARM/Maxknurn No. of Blnde <br />O K@prp/Rurimaye /Ani" Population No No. of Co nfk*V Cages <br />Sewage Disposal Method <br />Solid Waste Oisoosal AAedlod <br />Water Supply Source AniRtel Wesle Disposal Method <br />S. ❑ CONSULTATION FEE O NMNESS LICENSE <br />T. O PLAN CHECKING FEE O DANCE PERMIT <br />S. REAL ESTATE <br />REQUEST: Waw Wen NMpeCm 13 SanrpioO Tike Comperll/_- <br />Sewage srwn Inspection O Address Tete. No. <br />Escrow No. <br />Selier <br />Tobphona No. <br />Service Request For Data <br />SeOw Address <br />Seller Agent Name <br />1 hereby osntty telt 1 hew prepared tttls application and that tel work will be done M accordance with Son Joaquin County <br />ordinances. state laws. �roqulalie San Jooquin Leal healthDistrict. <br />APFLIC/1NT S SiL'a'?.'.TJRE XTItN Date <br />FOR DEPARTM FNT USE ONLY <br />Fee Is Ove: O• ^wsIALLY O PCR UNIT O MR aITE O EACH O .t«.wr I a R.o.I..e By im "v.31 O jwr . a R.o....e by h✓r 31 <br />FEE <br />' LESS <br />/1 US <br />rr.•wl r. <br />OI••CR <br />BASE EXPLANATION BILLING <br />DATE <br />RE►tITTANCi <br />DATE <br />/ <br />REI/ITTtO <br />4 <br />A0JNT DUE <br />REMIT <br />CHECKM <br />AMOUNT <br />09 <br />WSW <br />Af <br />ND <br />_--� <br />R.f...•.0 bw - EMS• <br />-� AIr r.ANi _ R�IL.B.. YLC[1.�1�• r0 <br />.Mv�iOw•.f Ni AL Mf Nrw .f .r�/e{f i. �./Cr� <br />10011 M•//\IOM •c! <br />.a•.•d rr�......1 <br />.o ..• X. .IOCNIrn•'l CA.l7e/ <br />