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'LA � APPO.aO.ra Wta so Ih.ala.., aha(t s\.aamw P""► y cm's."a. 0. 4\w. Ta Naw Tho AvvP <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> 1003040s'^AN()rOn APPLICATION N V1E1MCL!INVOLW O.01V! <br /> CON 'OA AF4041 ENVIRONMENTAL HEALTH PERMIT/SERVICES ` — <br /> atonaA ANt1Vw Lid.No. <br /> LXN04"ANPVr1 HM LETA4lW 28DrM Maaataa Rap W, No. <br /> weaaTTUTgN POKK PMA WATO 4AMUM <br /> .wA.MA MAL 951411 R111CTMM Cato( <br /> Pwtta9 YNCOCS AM SO MU <br /> /NKUI/MOM a95AC1a <br /> f AppRtallon Dale // BuaYt.aaFNan\.TO Appear On G+Ui'u•al'�, �.GWVZiL.[ <br /> Type P*nTA/So Rpu.aNd: 1 �' V u�, ( r f G *vu I <br /> App11cAM N«ta Ad rw //yy rAA�c-L —- <br /> _ Bwimws Tal.pht No. Z"IO Errarpar y T.I.phona No. <br /> Prop"Lo WXVAddr <br /> Pr.p«ly 0.rt,.. C' � - AddM <br /> ar ,. <br /> t Opawa Nun. 5✓.�mJL. Add(M. 71 . <br /> 1. F000 ESTAWLISHWNTS Total Bu"np Sp.Foolp. RMMw.nl Ma.Nwlnt sestiry Cam <br /> ❑ RESTAURANT ❑ F000 MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLAIT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE F000 STAND. ❑ LIDI/OR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ F000 DEMONSTRATION ❑ F000 VEHOOR <br /> D VEHORNO MACHWE&NM of ❑ MOBILE F000 PREP.UNIT ❑ VENDING VEHICLE <br /> ❑ F000 CROP HAAVESTWG/Ib.of Field EwVlo aas <br /> ALL APPLICANTS: Total Fwoloy.M Ytcbi l Operalora <br /> L NOUfpq <br /> ❑ "OTEL/MOTumo.of L1rft ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No,of Soaoa. P A Y M E N T <br /> 1 W ATu CIUALITY ❑ WATER SAMPLE(BacMM1M) . ❑ CHEM*CAL R E C E I V E D <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO.OF PUBLIC SERVEO(Corm tbra) <br /> L p OV 215 1986 <br /> RECRfATWF(AL NEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING <br /> L VECTOR CONTROL ❑ POULTRY FARM/MacVn No.of Blraa ENVIRO ME T <br /> ❑ KaMHJR mmam" ao. <br /> /Anitwaf Pcp\ tlon No. Hof Con&-*V C em AL HEALTH <br /> So**"Dl.00.w M.ptoa IT SER VICES <br /> 5.4w waw OtaO°ar Method <br /> W.MF supply Baha Atonal WARM Disposal MMtod <br /> L ❑ CONSULTATION FEE ❑ BItSUIEss uce mE <br /> T. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> L REAL CSTATi <br /> REOUIET: WnWWMIMtpacdon❑ SawtoMO TRAM Cow4.q. <br /> S.w.pa syaMtw 4rp.ction ❑ Address Tale.No. <br /> E.cro.r No. <br /> S.Iw S.IIw Addrtta. <br /> Ta4phora No. S.AM Apart Nam. <br /> Sarvica R.OI(a.l Fd 0.4 <br /> 1 P.Otey p fy pat I Irv. p""reo ON, appllcallon rtd Ilat Or w will M Oda M aocord.(tca with Salt Joapuin Cow <br /> MM. 4r., .no rvW.na ra0\A.Ibn.d Ra San Jo.p\wn Local H..Ith D1.trlcl. <br /> (APPLICANT'S SIGNATURE X TIlla Du. <br /> I FOR DEPARTMENT USE ONLY <br /> F— 4 Ow: ❑-Alw LY O Few t T O I MT( ❑ fn[i\ O M.+rr t 4 nl a rt j..+rr SI ❑A.tr t o n.o.....ti <br /> , w(urt <br /> O.S( Ar\Olr e�uM RE.."ANCCoff <br /> I wuan.T Due C�\(Otm <br /> La M <br /> rw0wwt rr+ __— <br /> MNY r• <br /> Orwlw I I <br /> orNM <br /> wRw�.rl N ._ _ _ fY4 w�nlr W ✓.raw Yn ...Ibrr W V tYn.....a <br /> �TKut_Arr\yM yt(yY.tO IMYO�alrrY rrlY\w NlYrrr.Iwwer. \Ytr �A/1\rM.t'.,IO Ytt• •rOUrOrI U.M\ <br />