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. IL <br />AppMceSwls WM N PA When aubeMtW ►roP.Ily ComplNaE. Be W.e Te n The AppkceMpn. <br />OAvalm" ludwom <br />A.'ILTCJVET I AAKWOR <br />CONTRACTOR AIdOA <br />LICENSE Afg401t <br />REaI*TMTION <br />IMMEA <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />1*M ERTAalL11OMM ksusm <br />PMLX POK& WATER EMIFUM <br />Mal. MARI IMricTw ts <br />-- — 14*IATAT ILAMON AM REMUS <br />NLSCUI/MaM 30"M / / r <br />GENERAL <br />IF VEHICLE INVOLVED, GIVE <br />Mak* <br />Lid. No. <br />Reghl. No. _.___ <br />Color <br />r Apolcatko Dale oli / 7 (W _ Business/Name To Appear On Permit 4:L1 IT VU rE , cnc \o <br />.Type Permit/Se", Revuealed <br />:.1 <br />Applkant Nane �Cf ��©1� (� �i7�Tff�S AOdreu r ' <br />_ Business 71�att phone No., y�Z — �lI Emergency Telephone No. <br />PropertyLocation/Ad rest---I�� FEJ' �� <br />Prop" Owner o/ (.(.I E5Iiima4air— Address <br />t Operalo/e Name <br />/('Ivl &J.LIF.Z Address K <br />1. FOOD ESTABLISHMENT& Total Building Sq. Footage Restaurant. M"Imum Seatkng capacity <br />❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br />❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br />❑ ROADSIDE FOOD STAND ❑ LIOUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br />❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br />❑ VENDING MACHINES(No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br />❑ FOOD CROP HARVESTING/No. of Field EmployM* <br />ALL APPLICANTS: Total EmployeM Including Operators <br />2 HOUSING <br />❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br />❑ MOBILE HOME PARK/No. of Spaces <br />1 WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br />❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br />NO, OF PUBLIC SERVED (Connections) <br />*. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br />S. VECTOR CONTROL ❑ POULTRY FARM/Maaimum No. of Birds <br />❑ KENNEL/Rumw*ya !Animal Population No. No. of Confining Cages <br />c..ru w..I. ni.r.r..at uwnvrt <br />Wales Supply Sour,* Animal Waste Disposal Method <br />L ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br />R [�LPLAN CHECKING FEE 1-1177-0 ❑ DANCE PERMIT _ <br />L HEAL ESTATE <br />REQUEST: Water Well Inspection❑ Sample❑ Title Company <br />Sewage System Inspection ❑ Address Tele. No. <br />Escrow No. <br />Seller Seller AddreM <br />Telephone No. Salley Agent Nana <br />Service Reouesl For Dale <br />I hereby certity that I hove prepared this application and that the work will be done in accordance with San Joaquin County <br />witinances, state laws, and ruies and regulations of the San Joaquin Local Health District. <br />APPLICANTS SIGNATURE X- ^'F=`�—'`t _5,_ Title Y,u,E Y.�L�L[LL.n�efp?7lUa to <br />I FOR DEPARTMENT USE ONLY <br />' FM Is DW: ❑ ANMIALLT ❑ ISR UNIT ❑ IEA SITE C1 EACH ❑ Jww I a RI wi, BY JwR.In 31 <br />FEE <br />LEM <br />PRORAI l(H1 <br />R US <br />PENAL Ty <br />OTIrER <br />OTHER <br />RK.•.wl Iryry <br />AIR IC ANI <br />❑ Juh 1 ♦ R.cK..a 01.AJT JI <br />REMIT <br />LINT pllE CHEC T) <br />AMCwNT <br />Rum K.ILu WDM MI�.«..1 <br />1.1E HA I I\IOY AVN_In M•DOI tTOCI IfY\CA MTI <br />I <br />RASE <br />706W <br />EYRANATION <br />BILLING <br />DATE <br />REMITTANCE <br />DATE <br />: <br />REMITTED <br />AMO <br />Rum K.ILu WDM MI�.«..1 <br />1.1E HA I I\IOY AVN_In M•DOI tTOCI IfY\CA MTI <br />I <br />•[T1yN LL1. !{lllMa r� IMVY1DwYINIAI HNA\Iw IIARil�lr wvlCl\ <br />Rum K.ILu WDM MI�.«..1 <br />1.1E HA I I\IOY AVN_In M•DOI tTOCI IfY\CA MTI <br />I <br />