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Yew <br /> Application[Will Be P ocose[d When Submitted Properly Comp"I he Sr ,.To Sign The Appllcatlon. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> MR LOCANT'� APPLICATION IF VEHICLE INVOLVED.GIVE <br /> C RACTOII AND/oA ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br /> 11#10 II AMMON <br /> Lid. No. <br /> LIcIMSE AND" FOO IlaetlM <br /> ra ES <br /> REGISTRATION ►ae1C Po"WAm unrum Regist. No. <br /> NUR R KA[STATE Rt[P[Clnn Color <br /> PSDLM RAMU s An RMILS <br /> ry rlsCUTANE sMVKU <br /> FAPPlieation Dale O,_ II 8usinesa/Name To Appear On Permit z�1��,M <br /> ipicip" <br /> Type Permit/SerWq80queeNtl:ApplkantName �/ Address L ._Business Tol No. Ems Telephone Location/ rest <br /> jProDertY Owner LZ Address <br /> L Operator's Name Address f7 l . <br /> t. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant.Maximum Seetino 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 Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> L HOUSING <br /> ❑ HOTEL/MOTELMo.of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spoon <br /> 1 WATER DUALITY ❑ WATER SAMPLE(Bacterial) ❑ CHEMICAL <br /> ❑ PUBUC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO.OF PUBLIC SERVED(Connections) <br /> a. RECREATIOPIAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds <br /> ❑ KENNEL/Rumvsys /Animal Population No. No.of Confining Cagn <br /> Sewage 04posal Method <br /> Solid Waste Disponi Method <br /> Wats Supply Source Animal Wnla Disposal Method <br /> 4 ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. P PLAN CHECKING FEEI-(16'iT FrW 0-4L — ❑ DANCE PERMIT <br /> IL. REAL ESTATE <br /> REQUEST: Wald Well invoction❑ SamPla❑ Title Company _ <br /> Sews"System Inspection ❑ Address Tele.No. <br /> Escrow No. <br /> Seller Seller Address <br /> Telephone No. Seller Agent Name <br /> Service Request For Data <br /> I hereby certify that I have Prepared this application and that the work will be dons in accordance with San Joaquin Coumy <br /> ordinances.state laws,and runts and regulations of the Sen Joaquin Local Health DistricL <br /> APPLICANT'S SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fw N Due:❑wtaRIALLY. O 4pr1T - O ret to • .O EACH O +a PAmk*e.Mlwkwy aT _ O Ja+r.+•iteeel.ee aY AMT s+ <br /> IILLOO REMITTANCE S RUNT <br /> BASE EXPLANATION DATE DATE REMITTED AMaaiT OLE dK{RED <br /> AALOIMT <br /> FEE tb ?/15A,& C7. z0 _ <br /> LEGS <br /> PROR Isom <br /> mdaik— <br /> ftm <br /> PENALLY <br /> OTNER <br /> OTME11 <br /> Cz— D/ISl�to � - G� <br /> R.n+.ee M pent +tlw,Ice fleN WMrO Wi.wea i <br /> APPucANT_aaTuaNALL_maua so: eNwoNr[NTu+NALTM narnn[avrcEs +en I.NAZ[LTON AK..P.O.Mr ones aTOCaTOIIuv+ <br />