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I <br /> jp@ApPMessie'"wo N 1 —*WbWA"*d Pro►eAy CeTvn'004-so Aure L Applk� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> APPLICATION IF VEHICLE INVOLVED,(PVT <br /> Lid. <br /> No. <br /> COOWPACTOR Al"000011 ENVIRONMENTAL HEALTH PERMIT/SERVICES L -- <br /> awoKaA^NC640R Id. _ <br /> Lx;tmw A.40110,01% Iesa �' Regial. No, <br /> ReGISTIlAT" AJC Pt"MATO" MIUM <br /> MAl UTAT!WaroCT"os Color <br /> POKTRY AAacm AM 91 &Z <br /> fApp0cAtion Data 4� Bus' Name To Appear On PwmN <br /> .Type PefmlVSefvicS Requested: —` J L/�r I✓ - <br /> Applicant// yName C C` "c e ri Address , / G l IG Tc <br /> «LC/ _ Business Telephone, L2 <br /> . �En»rgency Telephone No. <br /> Prop" Location/Addresa ^ � �� l% , C ` <br /> P'"'ty own« ,r�''L c� ' .,� �. Addressj— � ` <br /> t Op,rstor.Name, /y n r7/c�l Address /T &r <br /> 1. FOOD ESTASLISHMEKTS Total Building Sq. Footage Restaurant.MaxkTwm Seatkq Capadty <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 MACHINESRb.of ❑ MO&LE FOOD PREP.LMIIT ❑ VENDING VEHICLE <br /> ❑ F000 CROP HARVESTING/No.of Field Employees <br /> ALL APPLtCANT8: Total Empbreea ktdudlnp OPWOrk" <br /> Z HOUSING <br /> ❑ HOTEL/MOTEL/No.of Unlh ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaoes <br /> 3. WATER OUALITY ❑ WATER SAMPLE(Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO.OF PUBLIC SERVED(Connection") <br /> A. IIECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Ma"imum No.of Skids <br /> ❑ KENNEL/RWmmP /Animal Population No. No.ol Conflnkg Cages <br /> Sewage Disposal Method <br /> Solid Wath D"Method <br /> AnYlrt Wash Disposal Method <br /> Water Supply Soixcc <br /> fl. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> T. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> A. REAL ESTATE <br /> REQUEST: Wader Web Napadlon❑ Sample❑ Title Com pony <br /> Sewls"SYOW-Inspection ❑ Addmn Tele.No. <br /> Escrow No. <br /> Sellef Sector Address <br /> Tolspho"No. Sellef Agent Name <br /> Service Request Fa Date <br /> I homby comity that I have prspered this application and that the work will be done in socordance with San Joaquin County <br /> ordinances, state laws.wl rules and r*quistions'M.the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X� Dale / <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Duo: ❑.ANNEIALIY ❑KR EMIT ❑ "-A SITE ❑ EAC" ❑ J—.Wy I s R.o.I..r by jmW rY 31 ❑J,.M 1 a R.o...w M xM 31 <br /> REMIT <br /> BASE E11 I'L ANATIQN <br /> BILLING RE1.11i7 ANCf t AMOUNT DUE UrE GI(ED <br /> GATE DATf RF MITIED A/XJLMT <br /> — 1 Q�rMO0 qvit <br /> LESS <br /> Pff(N1A T I(Y1 <br /> 1•f NAL I+ 14 <br /> OTo,tR <br /> I Ij <br /> E4cw..n ey MI• R«..a Nn 1•.....I N.1 .. li... w..«I I «-.�-..1 1 <br /> ----- •►11 KAN1-11(1LIaM YLrnaua 10 fNv1a DM•If MI AI w1AL1•. I IL VON Avl.F0 M• Dal 01(X'■Inh (A• —I <br />