Laserfiche WebLink
•`• I Apaeeaaarw WIN M n aeee Whew Bh.aRl"*d PTeMroY C.ernpl/1el N alrre 1 _yn The APFB/+tt <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENEM <br /> "O"""'A/i0M011 APPLICATION w.IT�LE TNVOLVM amCGN�'DII AN000" ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> e1roR[A APOW001 Lid.No. <br /> 99"RSTAKMMMM waaewte <br /> ReWeTRA� Po""P"WATO"NPUM Real.No. <br /> 1AA."M am NTATe tnrecTon Color <br /> r«fTO SANCOU An MewLLl — <br /> / rxauwwa KU"M <br /> rApplication Oslo /IO—rT Bueln..arN.nhe To,. On �It <br /> Type PermlVSarolos ted: <br /> Applicant Na"j' Addren <br /> _ Talapltp� Emergency TN.pIroM No. <br /> property Location/ <br /> �Property Owner Addrew <br /> I Operable Name Address <br /> T. FOOD ESTABLISHMENTS ToW Building Sq.Footage ResWNYN,Maakmlm floating Capacity <br /> ❑ RESTAURANT O FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT O BAKERY <br /> ❑ ROADSIDE FOOD STAND. O LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE O FOOD SALVAGER O FOOD DEMONSTRATION O FOOD VENDOR <br /> O VENDING MACHINES/No.of ❑ MOBILE FOOD PREP.UNIT ❑ VENDING VEHICLE <br /> O FOOD CROP HARVESTING/No.of Field Employeae <br /> ALL APPLICANTS Total Engbyew Including Opemons <br /> L HOUSMQ <br /> O HOTEL/MOTELJNo,of Unib ❑ CERTIFICATE OF OCCUPANCY <br /> O MOBILE HOME PAPX/No.of Speom <br /> L WATER WALM O WATER SAMPLE(Bacterial) . ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO.OF PUBLIC SERVED(Connections) <br /> L RECREATIONAL HEALTH O SWIMMING POOL O SPA O WADING POOL ❑ NATURAL BATHING PLACE <br /> L VECTOR CONTROL ❑ POULTRY FARWIA"knurn No.of Birds <br /> O KO IfEL/Rwtwye /Animal Population rb. No.d Conhllrw Cava <br /> Sewage Disposal Method <br /> 3011d Wuete Dtaposal Me&" <br /> Water Supply Source Memel Waale Disposal Method <br /> L 13 G4N&4k*A*b9WFEE O BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE s ?0_ -Lr ❑ DANCE PERMIT <br /> L REAL ESTATE <br /> REQUEST: Wetsr Wall MtapectbnO Sample❑ TMe Company- <br /> Sowpa SyMnw inepacWon Cl Addreea Tale.No. <br /> Escrow No. <br /> Seller Seem Addreaa <br /> Telephone No. Saner Agent Name <br /> Service Request For Deni <br /> 1 hmstry cartity, that 1 naw prepared TMs application and that the work will be done In sce0fdance with San Joaquin County <br /> polnences. .tale lave,and iM and reg Pati *of The Sen Joaquin Local Health District. <br /> i <br /> APPLICANTS SIGNATURE X ` Title Dale <br /> F614 DEPARTMENT USE ONLY <br /> Fee It Due: ❑-ANNUALLY O ren urwr O rrA on O EACH ❑ J�1 a Aaa/Nee er AvAhwry 31 ❑ A..1 a Reesr\ee or Aft e1 <br /> , wE«rt <br /> BASE fxI ATgN ewfero MUMANCC / A..ouw WR 01EGtm <br /> DATE DATE REMITTED wuOlRrt <br /> off �a <br /> LEM <br /> nwDAAT.ON <br /> rfNY iv <br /> OrnQ l <br /> AInKM1_we IYaN YLfnWa(O. \NV` /NtY M/Ahrr N�ni•\Iwh1/IE IYrr nA1.\1..- .v\,10 Y. h\s \tQQrDy Ca/a/e1 <br />