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ApPl6eOMM velli w Pleeeaiasi When"WOW Property Colr4o*led Be!lure To SW Tho Applieatlan <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> �w6iNEEAS AM"111 IF VEHICLE INVOLVED GIVE <br /> AP+tiCANrs AND.OR TeeE QTANUGUED"moss ea Make <br /> _ONTRACTOR ANDiOA vtiPtip leets.Ratio saatFtlaa <br /> sROKEa AwWaR asst UTATI"Iworwfffi Lie No <br /> .rRNSfi AND/011 POKI.T"mom Ada+ Regist No <br /> .rPAT+ON S some (rOlOr <br /> %R <br /> �.Application Date 0 BuslnowNsrns To Ap ear On Permit <br /> M Type Perm+tiservlc*Requested y -` r..0 n °tfe ~ ` <br /> rc- <br /> !APpi+cani Name�.loo tea £ny' -�`"'' �"�"I tdn#'3 Addre a P6E'r, 401!3 9451 6 � <br /> Business Telephone No '4Z4 CL Qn Emergency Telephone No <br /> r <br /> Prooerty Location/Address <br /> _+ } <br /> Property Owner Address <br /> Operator s Name Address <br /> I FOOD ESTAl9tIbHMENTS Total Building Sq Footage Restaurant.Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> Q FOOD PROCESSING PLANT 0 COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> © ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER L7 FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING;MACHINES/NO of ❑ MOBILE FOOD PREP UNIT (3 VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No of Field EMpioyses <br /> ALL APPLICANTS Total Employees Including Operators <br /> 2 HOUSING <br /> -0 HOTEL/MOTENNo of Units ❑ CERTIFICATE OF OCCUPANCY <br /> 3 MOBILE HOME PARK/No of Spaces <br /> !1 WATER allAUTY ❑ WATER SAMPLE tBactehaq ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY 13 WATER HAULER <br /> 40 OF PUBLIC SERVED(Connections) <br /> RECREATIONAL HEALTH ❑ SWIMMING POOL o SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S VECTOR CONTROL ❑ POULTRY FARM/Maxlmum NO of Birds <br /> -Z -NNELlRunwsys /Animal Population No No of Confining Cages <br /> a�40 Disposal Method <br /> Solid Waste Disposal Method <br /> Animal Waste Disposal Method <br /> 4 `grater Supply Source —❑ CONsSuLTAT1OIt1I= <br /> 'moi ❑ PLAN CHECKIMO FE11 <br /> 6 REAL ESTATE <br /> i"EOUEST water well inspection❑ Sompie 0 Title Company <br /> i., Sewage System inspection ❑ Address Tet® No <br /> Escrow No <br /> i 5* Seiler Setler Address - .- <br /> ' Telephone No Seller Agent Name <br /> Service Request For Date <br /> l:.g t horsey Certify that I hate prapsmcd tW application and that the wo*will be ddno In 80001`118109 with San Joogkdn County <br /> ordinances !tate i and Tulsa alltl mp"Wo of the SAn Joaquin Local Health Diabiet. <br /> -Atli -�ii <br /> APPLICANT'S SIGNATURE X Title Ds" - <br /> i <br /> POR 021PARTIEENT U811 ONLY <br /> Foe Is Our 0 ANNUALLY d PER UNIT O PER s1Ta a EACH ❑ 1 a farads N rM11rrY 71 Q Jati 1 a ReLar.eaOIly July 71 <br /> i AT <br /> OILLINO REMITTANCE s AMOLPT DtM CHECKED <br /> " BASE ' E%PLANATn7N PATE OATt1 IIEIWTTEO Ak*"T <br /> �r i <br /> REE <br /> LESS <br /> PRORATION <br /> PLUS + <br /> liNALTY <br /> pTMER <br /> I <br /> OTHER <br /> a«Mwe L11r Da10 aocelel•io Pawn No + D� ras>aerrl <br /> • _T .ar.r�rr�AP7..00 N. rnsw•m RSM 11/A1 rw MMMT+�eMPP{ �W1'1 tlAL "me AW en am ese OMCUTM CA <br />