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WORK PLANS
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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MOUNTAIN HOUSE
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19685
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1600 - Food Program
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PR0548439
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Entry Properties
Last modified
9/28/2023 2:28:19 PM
Creation date
9/28/2023 2:28:01 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
1600 - Food Program
File Section
WORK PLANS
RECORD_ID
PR0548439
PE
1625
FACILITY_ID
FA0027663
FACILITY_NAME
AAPPAKADAI INDIAN CHETTINAD
STREET_NUMBER
19685
Direction
S
STREET_NAME
MOUNTAIN HOUSE
STREET_TYPE
PKWY
City
MOUNTAIN HOUSE
Zip
95391
CURRENT_STATUS
01
SITE_LOCATION
19685 S MOUNTAIN HOUSE PKWY #150
P_LOCATION
03
QC Status
Approved
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Tags
EHD - Public
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ne€6<7_ FA <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Restaurant <br />FACILITY ID #SERVICE <br />(\e,) <br />„...., REQUEST <br />,>Mcjtcp, <br /># <br />OWNER /OPERATOR L_"\'E i A <br />CHECK if Raju Kalidoss BILLING ADDRESS <br />FACILITY NAME <br />Aappakadai Indian Chettinad Restaurant <br />SITE ADDRESS <br />19685 <br />Street Number <br />S. <br />Direction <br />Mountain House Parkway <br />Street Name <br />Mountain House <br />City <br />95391 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />5339 Street Number <br />Birch Grove Drive, <br />Street Name <br />Crry STATE ZIP <br />San Jose, CA 95123 <br />PHONE #1 EXT. <br />( 408 ) 607-2602 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Simon Lin CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />Eleven Ten Architects <br />PHONE # <br />( 408 ) 505-3805 <br />EXT. <br />HOME or MAILING ADDRESS <br />480 Boynton Ave, #5, <br />FAX # <br />( 1 <br />Crry San Jose, STATE CA ZIP 95117 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: t4 DATE: 04.25.2022 <br />PROPERTY / BUSINESS OWNER!: OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 Architect <br /> <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required <br />Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available ancltme time it is <br />provided to me or my representative. ENT <br />rmaut-rvED <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: APR 2 6 2022 <br />smitauau, iv cou,.,,,. teoluevolvuENTAL-, , <br />DeRinion. <br />ACCEPTED BY: <-; - WI I 61-- EMPLOYEE #: ( 0 .t,-tr DATE: I( ( 2._ 04) Li <br />ASSIGNED TO: L i vk kok v,e__‘_. EMPLOYEE #: y ‘,ci DATE: 9 ( <br />Date Service Completed (if already completed): SERVICE CODE: i b 0 I P 1 E: -s-- 2_ 3 <br />Fee Amount: 4' 4 iv cc Amount Paid ,/..1.5-ts2 — , Payment Date 412_64 2_2_ <br />Payment Type (IA gc, Invoice # <br />.etlEitn; I 11-f2 261(1/3-q- <br />Received By: ta7/7( <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003
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