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a Arrel4eeana E[M N n. . d Wren eflaw\KMe FwePerry' Ce1115E eL Be a..fw rqw Tlwe APeeceeo <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> APPLICATION IF VEHICLE INVOLVED,GM <br /> �COWPACT001 APAWO1 ENVIRONMENTAL HEALTH PERMIT/SERVICES -- <br /> Irlon AKYOn Lw. No.__ <br /> 11X0![AND/001 49441 EITAMMeMDf1L Reg4l. NO. <br /> ft♦--iIOM FfrM1C PO"WATD aANPUNG <br /> E,Lwa to MA ESTATE IeiFECn@M Color <br /> PM1TIrT BANCe=AM S[Ea1tu <br /> Ma[D1Aeleq <br /> 2111110m <br /> r Apoluhon Date Buun.wN, TOCA Permit nuc1 ,17-Pnn,I-Sewe7-c <br /> eT ype P.K/Se 'u Rspu"led: Lh C.VaAu..y <br /> ry <br /> r Apdtunl Nemo --�I:1[/S"o /3 _c�yc'iT. Addrw <br /> _SuEimse Telept\one No. Emergency Telephone No. <br /> Property Lout orVAddrw <br /> l7l prop" Onw o/f/ - 9 Addivee . PO 'd .5r0r-/—?Sec-vS- <br /> Operelo(a NamKIvA{ — Address- <br /> 1, <br /> ddrw T <br /> 1, FOOD ESTABLISHMENTt Notal Building So, Footage Reeteurant.M"I rwm Seatkq G <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT O COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND. ❑ LIOUGH STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION O FOOD VENDOR <br /> O VENDING MACHINES/NO.of O MOBILE FOOD PREP.UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No.of Field Empbywmi <br /> ALL APPLICANTS: Total Emplorwe kck,6 rlp Operator. <br /> 2 HOUftND <br /> ❑ HOTEL/MOTE1JNo.W Lkrka O CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No,of Specwe <br /> 1 WATER QUALITY O WATER SAMPLE(Becterlal) - ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM O SURFACE WATER SUPPLY O WATER HAULER <br /> NO OF PUBLIC SERVED(Corxwctlone) <br /> L REC IFATTONAL HEALTH O SWIMMING POOL ❑ SPA ❑ WADING POOL O NATURAL BATHING PLACE <br /> L 'VECTOR CONTROL ❑ POULTRY FARM/Muimum No.of Sl ds <br /> O KEHNQ/flu,,em" /Animal Population Na No.of ConhJ W Cages <br /> Seer"Disposal Medrol <br /> Saw Waste D,wua1 M.thW _ <br /> W~&mpty Sarco AnlnW Wasae Dlapo"Medlod <br /> L ❑ CONSULTATION FEE O BUSINESS LICENSE <br /> T. p,PLAN CHECKING ❑ DANCE PERMIT <br /> L REAL ESTATE <br /> REQUEST: Waw Wet kapectfonO SrnpleO Tkw ConWery <br /> Sewaq SyeMrn inspection ❑ Addreae Teta No- <br /> Eacmw No. <br /> Seller SNler Addrame <br /> Telephone No. Seller Agent Name <br /> Service Reol♦eal For Data <br /> 1 rmmby cedky that I have Prepared tits application rid that the work will W dory M aw""nce with San .ioawm County <br /> ordiruncea. stale levee• rued and repulalipna of the San Joeouin Local Health Dutrtct. <br /> APPLICAP,ITS SIGNATUR X TIIN <br /> 1 FOA DEPARTMENT USE ONLY <br /> F« Is D.: ❑ A.aa Lv O row tAeT ❑ a[lf DIT[ O EACH O lerrfy t a n.oM..e By JMwrr.11 er AIy 1\ <br /> ' .lural n[M."AMCC E MEUIT <br /> 9A5f [aILAMATfON w..plMT(AA GMEClIm <br /> PATE Owlt wEMITI[O wuo\wfT <br /> Fit 90,o <br /> \rss �a <br /> LESS !1(Y♦ .. r <br /> . / ///77 <br /> rr N.1 n G . 01 <br /> M.[.+.e M rMu Mr pp••o r....n 4n u......I V.• u.+..f len.�.vl <br /> awTIC AYI_1\rIWaALLP�W\!O ruvYOwulMl4 •.l.\rn.e... f.wl...Cra \r1I n.I1\fOn..l.•O ti• rr •fOCwfM Urw. <br />