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'AFw>M N «II^xnod Property CeTgwte< So A+* a c.1Eon <br />SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br />e.oe+e1" AMWOR APPLICATION IF VEHICLE INVOLVED. GM <br />APPL)CA tT1 AiEoaOsl brake <br />CONTPACTOR ANDOOR ENVIRONMENTAL HEALTH PERMIT/SERVICES Lid � <br />6PKW A AND/OR /ea tiamm 11morm Pousm <br />ucv+st ANO"OR PVKJC Pesti WATU aanrume Regial. No. <br />._eO42TIlAT1Ok _- "m UTATI ICsrEGTm" Color <br />mumsem POKTf1Y RAbCm An KLOK S <br />90VOCU (7— <br />r ppllcatlon Date Busesa/Name To Appem O <br />inn PWMA <br />,,Type PwmtLrS_r ce Request --4:-. <br />tAppllcanl Name (1 esa <br />Business Telephone No. Emergency Telephone No. <br />Property Locatilxt/Addresa �� �l •- `�`'� �� � �"� <br />Ply Owner Address <br />t Operato(s Name Address <br />1. FOOD ESTABUSHMENTS Total B-0ding Sq. Footage Reetsurant, MaxkTwjm Seatfnp Gpadty <br />❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br />❑ FOOD PROCESSING PLANT ❑ COW,AISSARY ❑ ICE PLANT ❑ BAKERY <br />❑ ROADSIDE FOOD STAND. ❑ LKX)OA STORE ❑ BAR ❑ ITINERANT RESTAURANT <br />❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br />❑ VENDING MACHINES/No. Of ❑ WxmLE F000 PREP. UNIT ❑ VENDING VEHICLE <br />❑ FOOD CROP HARVESTING/Nm of Field Employees' <br />ALL APPLICANTS: TotLl Employees kTdudkV OPorstors <br />L HOkM NO <br />❑ HOTEL/1.:OTEt1No. ofun is ❑ CERTIFICATE OF OCCUPANCY <br />❑ MOBILE H04AE PARK/No. of Spaces <br />1. WATER GUALM ❑ WATER SAMPLE (Bacterial) ❑ CHEV4CAL <br />❑ Pl18LIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br />NO, OF PUBLIC SERVED (Conr»di ) <br />4. r .CREATIONAL HMTH [I SWPOOL ❑ SPA 13WADI POOL ❑NATURAL BATHING PLACE <br />>L VECTOR CONTROL ❑ POULTRY FARINktaxkrwm NO. of Blyde <br />❑ KENNEL/Runw"v /Anima! Population No. No. of Confkting Cages <br />Sewage Disposal Method <br />Waser Suppty SoixCe Anlnnl Wash Disposal I.NtI►od <br />IL ❑ CONSULTATION FEE _ � � � "�"' 1 ❑ 8USL4ESS LICENSE <br />T. ❑ PLAN CHECKING FEE ❑ DANCE P£FIMIT <br />L REAL ESTATE <br />REQUEST: Wstsr Weil kmpection0 Sample Tkie C WpWj. <br />Sewsgs SyMsrn Mepecbon ❑ Addnm Teas_ NO. <br />Escrow No. <br />Seller Seller Address <br />Telephone No. Seder Adam N— <br />Service Request For Date <br />I hereby oertlty that 1 here prepared tNs appOcstlon and that eve work will be done in socor4anoe with San JO,aquin County <br />ddlnances. state taws, end rules and reputations d the San Joaquin Local Heahth District. <br />APPLICANTS `1''„AT ARE X_ <br />Title <br />Dale <br />FOR DEPARTMENT USE ONLY <br />c.. Is rT,..• (7...ea♦u E r ❑ KA f/rMT ❑ IKJI 6+T1t ❑ EnCM ❑ J.I.rT <br />t o Rook—d by J—...•v ] t ❑ J.+r I a P -0--w Dy J'Ar r <br />lrss <br />q cal <br />e1LLM♦O <br />rEfAAITTAMGC <br />s_ <br />AAApu/+T DuE <br />U <br />(XftAMAT/OM <br />DATE <br />DAT( <br />nE UITI(D <br />..AAOVIiT <br />- _ <br />- <br />---•EUtID <br />(). j — }J -- -- -- <br />— -- <br />-- --- <br />.l 11S <br />OL.•IA <br />J <br />rlrvl CP f.lu w r Atfs <br />l u.r •Y W..d Il.p.-�.A <br />1"lE wA/rl to. .n -.O ate.n 010C■I0-k CA ate+ <br />�1 <br />A ��1 K A w l_. <br />r T �♦AM ca l fLl.a[ • to <br />rlrvl CP f.lu w r Atfs <br />l u.r •Y W..d Il.p.-�.A <br />1"lE wA/rl to. .n -.O ate.n 010C■I0-k CA ate+ <br />�1 <br />